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Training Vegetable Parenting Practices Through a Mobile Game: Iterative Qualitative Alpha Test

Training Vegetable Parenting Practices Through a Mobile Game: Iterative Qualitative Alpha Test Background: Vegetable consumption protects against chronic diseases, but many young children do not eat vegetables. One quest within the mobile application Mommio was developed to train mothers of preschoolers in effective vegetable parenting practices, or ways to approach getting their child to eat and enjoy vegetables. A much earlier version of the game, then called Kiddio, was alpha tested previously, but the game has since evolved in key ways. Objective: The purpose of this research was to alpha test the first quest, substantiate earlier findings and obtain feedback on new game features to develop an effective, compelling parenting game. Methods: Mothers of preschool children (n=20) played a single quest of Mommio 2 to 4 times, immediately after which a semi-structured interview about their experience was completed. Interviews were transcribed and double coded using thematic analysis methods. Results: Mothers generally liked the game, finding it realistic and engaging. Some participants had difficulties with mechanics for moving around the 3-D environment. Tips and hints were well received, and further expansion and customization were desired. Conclusions: Earlier findings were supported, though Mommio players reported more enjoyment than Kiddio players. Continued development will include more user-friendly mechanics, customization, opportunities for environment interaction, and food parenting scenarios. (JMIR Serious Games 2015;3(2):e6) doi: 10.2196/games.4081 KEYWORDS mobile games; games for health; serious games; pediatric nutrition; parenting Because traditional interventions to increase child vegetable Introduction intake have had little or no effect [7], innovative approaches are needed. Serious games provide a behavioral intervention Vegetable consumption is protective against several chronic opportunity to increase child vegetable intake, which has had diseases [1,2]. Children’s dietary practices tend to track into a positive impact on health-related behavior change [8]. A adulthood [3], and parents play an important role in establishing mobile game, Mommio, designed to teach parents of young healthy dietary habits in their young children [4], but often children about vegetable parenting practices [9] is currently report difficulty getting their child to eat vegetables [5,6]. under development. Games for health predicated on a combination of social cognitive [10] and self-determination http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al theories [11] are believed to increase likely effectiveness in Game Description promoting behavior change. According to social cognitive Mommio is a first-person role playing video game that simulates theory, a game that provides a player with relevant knowledge, a mother interacting with her preschool age child (called skills, self-efficacy, and motivation is likely to result in behavior “Kiddio”). Kiddio hates veggies. Players can customize their change [12]. In self-determination theory, personal values are Kiddio’s name, gender, skin, and hair color. The game takes an aspect of relatedness; fulfilling values should increase place in a 3D world that includes the player’s virtual house, intrinsic motivation [12]. In Mommio, targeted desired behavior complete with working kitchen and numerous common includes use of appropriate vegetable parenting practices [13]. distractions, such as a begging family dog and booming A recent meta-analysis revealed that games were most likely to televisions. The player navigates by double-tapping the ground contribute to learning and behavior change when end users were to move inside the world and using an onscreen thumb stick to involved as testers of game mechanics (A. DeSmet, written change perspective. Single tapping a character (Kiddio or the communication, January, 2015). The purpose of this alpha test dog) or a game object (refrigerator, food item, etc.) starts an was to obtain feedback from mothers of preschoolers on interaction. At mealtime, Kiddio prompts the player to action Mommio game mechanics at an early stage when changes could by exclaiming “I’m hungry.” The player must then select a still be made. vegetable recipe from the kitchen’s recipe box as a side dish for lunch. The recipe box features simple recipes for a variety A prototype version of Mommio, Kiddio, was tested by mothers of vegetables, and non-veggie recipes (eg macaroni and cheese) who were similarly interviewed about their experience [14]. which result in a loss if selected. Once the player and Kiddio Substantial changes (eg 3D environment replacing a 2D are seated at the kitchen table, the player tries to get Kiddio to environment, enhanced recipe selections, additional interactive eat the vegetable, and Kiddio refuses. items) were made. The current alpha test (ie testing game features when changes can still be made) of one Mommio quest Mommio is not an easy game to win. The player can try different was to reaffirm conclusions drawn from Kiddio testing [14], as food parenting strategies, such as choosing from effective and well as obtain feedback on new, more sophisticated features to ineffective statements to say to Kiddio, or modifying the produce an effective game that trains vegetable parenting environment (eg turning off the television). The variety of practices among mothers of young (3-5 year old) children. statements that can be selected to say to Kiddio could be modified by voice tone (gentle, firm, or harsh) and facial Methods expressions (happy, neutral, concerned, or angry). If the player makes an effective move, she comes closer to winning the game. Sample and Recruitment If she selects ineffective ways for dealing with the child, she Mothers of 3-5 year old children were recruited after obtaining moves toward losing the game. At the conclusion of each approval from the Baylor College of Medicine’s Institutional Mommio quest, Kiddio either tastes the vegetable to signify a Review Board. Mothers who reported no difficulty getting their victory, or runs out of the room, indicating a loss. child to eat vegetables or were not 20-40 years old were At the conclusion of the quest, players are led through a series excluded. Recruiting took place through digital and printed of screens that asks them to select a parenting value that is flyers distributed throughout the Texas Medical Center, and important to them, from which tailored motivational messages from the Children’s Nutrition Research Center’s volunteer list. will be delivered, as well as a plan for strategies to use at home All mothers (n=20, demographics described in Table 1) provided to increase vegetable consumption based on the selected value. informed consent. http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al Table 1. Demographics.  Demographics n (%) Child Gender Boy 13 (65%) Girl 7 (35%) Highest Education Completed High School graduate or GED 1 (5%) Technical school 2 (10%) Some college 7 (35%) College graduate 5 (25%) Post Graduate Study 5 (25%) Annual Household Income Less than $30,000 4 (20%) $30,000 to $60,000 8 (40%) Over $60,000 8 (40%) Ethnicity Hispanic 9 (45%) African American 6 (30%) White 3 (15%) Asian-Non Vietnamese 1 (5%) American Indian 1 (5%) Employed Yes 14 (70%) No 6 (30%) Primary Responsibility for Feeding the Selected Child Me 13 (65%) Shared among multiple people 7 (35%) Marital Status Married or living with a significant other 13 (65%) Single, Never married 6 (30%) Divorced. Separated, or Widowed 1 (5%) provided a player tutorial guide upon starting their game session, Procedures and were encouraged to ask questions. The interview contained Mothers scheduled one hour time slots at their convenience to 27 questions, with additional probes and prompts (Textbox 1). play Mommio on an Apple iPad tablet under researcher At the conclusion of the interview, participants were thanked observation. Qualitative interviews about their experience and compensated $25. followed, conducted by a trained interviewer. Participants were http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al Textbox 1. Interview questions. 1. What do you think the game is about? 2. What, if anything, did you like about playing the game? 3. What, if anything, did you not like about playing the game? 4. What do you think about the name of the game? 5. What did you think about personalizing the child character? 6. What did you think about being able to pick different things to say to the child character? 7. What did you think about the child character’s reactions to your statements? 8. What did you think about being able to choose recipes to offer the child character? 9. What things did you do in the in the game that you could use with your own child? 10. What did you think about the artwork or graphics for the game? 11. What did you think about moving around the house? 12. What did you think about interacting with items in the game environment? 13. How do you think you can win this game? 14. What did you think about the possibility of game points? 15. What do you think about receiving feedback at the end of gameplay? 16. What did you think about the game’s question about “What is most important to you”? 17. What did you think about the “most important to you” choices offered? 18. What are your thoughts on receiving tips to practice at home? 19. What did you think about having a website as an additional resource? 20. Today you played the “lunch” level of the game. The finished game will include other situations like car trips, dinners, grocery stores, and fast food restaurants. Would you play a game like this? 21. Do you read nutrition labels while at home or in the grocery store? 22. If the game was a free app game how likely would you download it to play? 23. How much would you be willing to pay for this app game? 24. If you had to pay for this app game, how likely would you download it to play? 25. On a scale of 1 to 3, where 1 is “not difficult” and 3 is “very difficult,” how difficult is it to get your child to eat vegetables? 26. Using a 1 to 4 STAR rating scale, how would you rate the game? 27. Before we finish, is there anything else you want to tell me that you haven’t had an opportunity to say? A majority of the sample (12/20, 60%) found navigating the Data Analysis game environment frustrating. This was largely due to the thumb Interviews were audio-recorded and transcribed in full. All stick, which was felt to be “overly sensitive” and “very hard transcriptions were double-checked against the original to control” (see Figure 1). Over half of the mothers (12/20, recording before importing into NVivo (Version 10.0, 2012, 60%) found the circle thumb stick difficult to use, and a few Doncaster, VIC, Australia). Thematic analysis [15] was used (2/20, 10%) found the feature to be a deterrent to engagement. to code each response within the questions posed. Transcripts For some (6/20, 30%), the thumb stick mechanic was a learning were double coded to ensure reliability. Differences between curve that “took me a while to get accustomed to.” A handful coders were adjudicated by discussion and consensus. of mothers (3/20, 15%) suggested using direction arrows instead of or in conjunction with the thumb stick, or to maneuver by Results dragging “not the circle, just with your finger.” Less than a quarter of mothers (4/20, 20%) mentioned liking the thumb Game Elements stick feature. Most mothers completed three iterations of the game. On Nearly all mothers (19/20, 95%) enjoyed the ability to average, gameplay consumed 20 (SD 7) minutes. Patterns personalize the look of the child character, although some (5/20, emerged in regard to the design of the Mommio game. These 25%) wanted more hair options while others (7/20, 35%) wanted themes reflected on game look and feel, as well as mechanics more clothing options, which “would feel more like it’s my not related to vegetable parenting. child.” Nearly all participants (19/20, 95%) enjoyed naming the character after their own child, which increased the realism http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al of the story. A majority of participants (16/20, 80%) would have I did try to get a box of something off one of the liked to pick the child’s personality (ie temperament [16]) in cabinets, but that didn’t work either. So just having the game, as this would be the option would be good. Many participants liked interacting with the environment in more realistic to what parents or guardians have to other ways, such as turning off the television (9/20, 45%) and deal with when they’re trying to encourage a kid with speaking to the dog (5/20, 25%), which increased the realism a certain type of personality to eat their vegetables, of the environments and was “something extra to do…it was because all kids are not the same. neat”. The main action of the game took place in the kitchen of the home. Perhaps due to this, nearly half of the mothers (8/20, Three quarters of participants said that they liked the graphics 40%) were not aware that the navigable 3D environment and looks of the game. About one third of all parents thought included the entire house and yard. This was reflected in that the home and kitchen looked modern or realistic (6/20, comments such as 30%), liked the bright colors used (5/20, 25%), and thought that the art looked professional (5/20, 25%); though a minority I wish we would have been able to move more around mentioned (2/20, 10%) that the art looked like cartoons tailored the house to make it a little interesting for preschoolers. A few participants (3/20, 15%) thought the and art was passable, but unremarkable, such that they were I didn't try to go out past the kitchen. But I'm sure not sure it would win awards necessarily, in terms of that's the only place you'll be able to go its, like, graphic ability, but it was totally fine. Most (16/20, 80%) thought that double tapping the floor to The kitchen and home environment were noted as “nice and move in the environment was either good or fine. Four mothers cute” and about a quarter of participants (4/20, 20%) mentioned thought this countered some of the difficulty experienced with enjoying exploring and interacting with the realistic kitchen, the thumb stick feature, saying “I thought that made it easier, which was stocked with grocery items. a lot easier”. All mothers agreed receiving feedback at the end of gameplay However, a few (3/20, 15%) mothers did not understand or use would be beneficial. The majority (13/20, 65%) thought that this feature. feedback should occur at the end of each episode (level), although a few (3/20, 15%) thought that it should occur after a Thirteen mothers liked interacting with items in the game few episodes taking place in one sitting. The most commonly environment, with 25% (5/20) mentioning that this feature made preferred method of delivery was in-app, followed by email. the game more realistic. However, three mothers were Common requests for feedback content included points earned, unclear whether doing any of those things has any quality of food choices made, tips to improve gameplay, and impact on the game, like turning off the TV. Is it evaluations of parenting statements selected. Some participants important to do that as part of the process or are these (7/20, 35%) wanted to see a tie-in to the learning goals of the just things that are there for no particular reason? game through feedback, All participants opened and closed cupboards in the kitchen because if I’m going to take time to play the game, environment, and 35% (7/20) enjoyed seeing the contents of then I would want to receive something from it the kitchen and nutrition labels of food. Almost half of all beneficial that I could use. participants (9/20, 45%) wanted more available interactions with items in the kitchen, saying things such as Figure 1. Joystick mechanic. http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al All but one mother found the child’s reactions helpful in Learning Content knowing how well they were doing in the game, as “you can For the video game to be effective, it must adequately express read by the facial expressions” The mother who did not find and incorporate vegetable parenting messages. Several themes the child character’s reactions helpful cited a lack of variation were found from participant discussion of learning content. in expression, similar to the reasons for the child character’s All mothers enjoyed being able to select statements to say to unexpected reactions. Kiddio and found the available statements realistic (see Figure Upon first playing, game goals and objectives were unclear to 2). Several (6/20, 30%) mentioned the variety of statements many participants. Some (8/20, 40%) “had no clue what to do,” available to them, which which resulted in confusion or frustration. Mothers who was great because there were some things I wouldn't expressed this either consulted the provided user guide or asked necessarily say to my child. But I found something the researcher for help before making strides in game that fit me and my personality on how I would respond progression. in the situation. Most mothers (19/20, 95%) liked the vegetable recipes provided Others (4/20, 20%) thought the selectable statements were through the in-game recipe box and that recipes included limited and should be expanded to not get repetitive in future instructions and nutrition information. Some (8/20, 40%) pointed levels. out real-world benefits for including this information, and that the recipes may Every mother interviewed found statements that she would use or has used with her own child. Most commonly mentioned help me to learn like what's healthy, what's not statement types noted as effective in the game were healthy. I guess it's going to be good for kids as well. encouragement to try a vegetable or take a few bites and trying The vast majority of mothers (18/20, 90%) said they would be or preparing vegetables with the child. The most frequently interested in using the recipes at home with their own child, or mentioned ineffective strategies were bribing with food or already do. Nearly all mothers (18/20, 90%) said they would activities after eating and telling the child that he should sit at be interested in learning how to make the recipes at home. A the table until he eats his vegetables. minority of mothers (2/20, 10%) found the recipes too simple Many players thought that the child character’s reactions were and thus already knew how to make them. realistic (17/20, 85%) and similar to their own child (15/20, Almost half of mothers (9/20, 45%) would prefer to receive 75%). A few mothers mentioned liking the character’s realistic game recipes though an in-game recipe box with an option to attachment to a favorite toy (3/20, 15%), as well as Kiddio’s select individual recipes to send to their email. Other preferences responses to player actions. Many (8/20, 40%) pointed out included only the in-game recipe box, a combination of email differences between the child character and their own child, and website, featured in the app but outside of gameplay, and including differences in stubbornness (3/20, 15%) (the child on a website. Frequent responses to ideal recipe content, aside character was perceived as both more and less stubborn than a from ingredients, included calorie count, instructions, nutrition parent’s own child), responses to bribery (2/20, 10%) (the content, and serving size. character does not respond well to bribery, real child does), and activity level (4/20, 20%) (own child talks and fidgets more, Nearly half of all participants (9/20, 45%) thought the player including eating items on plate to avoid vegetables). wins the game by getting Kiddio to eat vegetables. Several additional mothers focused on the parenting strategies as ways While a large majority of mothers (17/20, 85%) thought Kiddio to win, such as watching one’s tone while speaking (6/20, 30%), responded mostly as expected, three participants found that selecting the right parenting statement (4/20, 20%), and using there was not enough variation of child animations to portray generally effective communication strategies (2/20, 10%). Three appropriate reactions, as mothers did not mention parenting strategies, but indicated that it seemed as if it was always stuck on a certain, ‘I picking healthy foods was the way to win. don’t want it, I don’t want to do it’ kind of look. http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al Figure 2. Playing a meal. The mother who disagreed thought that a game was not the best Real World Application format for receiving parenting tips. Preferred methods of A series of questions asked participants to reflect on personal parenting tip delivery and scheduling time to practice were values regarding parenting practices. This included a game email, electronic calendar app or other mobile scheduling prompt, which asked participants to practice vegetable parenting program, in-game only, and text message. based on a parent-selected value. Participants generally were All participants indicated at least one food parenting practice open to a real-life crossover, given their current values and from the game they either had used in the past with their own habits. child or would use in the future. Popular responses include being A game storyboard featured a question asking players to select aware of vocal tonality or facial expressions when speaking to what value (e.g. being a role model, being spiritual) was most the child (see Figure 2), staying positive or encouraging, sitting important to them given multiple options. Half of all mothers down at the table with the child for meals, role modeling healthy interviewed (n=10) thought this question was good or okay. habits, choosing healthy vegetable recipes, involving one’s child However, six mothers found it confusing, commenting “I didn’t in the meal preparation process, and general communication relate this to the game really,” and “I wasn't really sure of strategies. exactly what the point was there”. The vast majority (17/20, Fourteen mothers reported reading nutrition labels in the grocery 85%) understood the question, although two mentioned they store. Those who read labels used the information because they needed more context to understand what the question was wanted to feed their child healthy foods, prevent disease related asking. to unhealthy eating, be aware of what is in their food, make A quarter of participants (5/20, 25%) found selectable value choices between similar products, and limit certain nutrition options to be good or okay. A handful of mothers (4/20, 20%) elements, such as sugar. agreed that When reading nutrition labels, mothers said they looked for being spiritual-even though it may be important to numbers for sugar or carbohydrates, calories, sodium, fat, you, but I think it’s just so far and apart from the protein, and portion size. Five mothers reported looking at game ingredient lists in addition to nutrition panels. Several of these components were listed on nutrition labels provided for each and would have liked to see this value replaced with something recipe in the game. About half of mothers interviewed (11/20, that fits better with the game and other available options. Most 55%) thought all recipes in the game should have these nutrition (15/20, 75%) said the selectable options made sense to them, panels, and even more (14/20, 70%) wanted to see the but a couple said they were not sure how to answer given ingredients of a recipe in the recipe box before making a provided choices. All mothers interviewed thought at least one selection. of the listed values applied to them, though five would have liked to select more than one value. Future Production All mothers indicated they would be willing to try out game Evaluations of the game as a whole and thoughts about its future tips with their own child, largely willing to consider parenting were presented over the course of each interview. More than practices that could help with their parenting, saying “if you half of mothers interviewed (13/20, 65%) thought that a can get advice and help from others, it's always a plus”. All but companion website would be good or helpful. Mothers suggested one mother agreed that receiving tips to practice at home would the website include recipes with nutrition tips, parenting tips, be helpful, as forums or user generated content, links to external resources, and the game itself. it helps that you have those tips and that you've practiced, and you have some information under your A larger, more complex game that featured several mealtime belt and ready. contexts was of interest to a large majority of mothers (17/20, http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al 85%). Those interested in playing said that variety would make feedback after gameplay would make the game better, as well the game more interesting and would be helpful delivering as the addition of audio. parenting tips for different scenarios. A few mothers (3/20, 15%) mentioned wanting grocery store help specifically, while Discussion a few others (2/20, 10%) mentioned tips for car trip food Results were generally consistent with earlier findings [14]. parenting. Both studies uncovered initial confusion by players about the All but one mother said a game that varied in context would game’s objective, but understanding of the game’s primary goal seem more like their real life. One mother said that it would after at least one level was played [14]. Mechanics and not, due to the fact that nearly all meals her family consumed navigation were considered difficult in both studies [14], were in the home. although they had been modified after the earlier test. Customization was appealing for both the child character as Most mothers (15/20, 75%) said they would likely play multiple was the ability to choose what to say and do in the game meals in a row in the proposed expanded version of the game. environment [14]. Feedback was a desirable in-app feature Those who mentioned not wanting to do this commented that across both studies, as was Kiddio’s animations and reactions, “trying to remember too much at the same time is not going to though both samples suggested ways they could be improved be effective, either,” and that playing the game in small chunks [14]. Both studies found that while asking players to choose a would let them retain tips and information for future use. value was fine, mothers had a difficult time selecting only one When asked how likely they would be to download the game parenting value given the options displayed, though these if it were free, the large majority of mothers (17/20, 85%) said options were different in form and number for each study [14]. that they would very likely do so. Reasons included it “would Some findings between Kiddio and Mommio differed [14], be beneficial” or useful to parenting, that the game supports perhaps due to enhancements in the game itself. Mommio interactive time with one’s own child if they play together, and participants rated the game higher; with more saying they curiosity. Two mothers who would not download the game for “loved” the game [14]. Many more Mommio than Kiddio players free reported not liking any types of games, and the remaining were interested in playing the game if it were free or if it had a mother was not sure whether or not she would download the small cost, suggesting the changes made enhanced its appeal. game until it was expanded further. Aspects of social cognitive and self-determination theories were Two mothers reported being slightly less likely to download endorsed. Participants reported gaining knowledge through the game if they had to pay for it than if it was free. Three would situated learning and environmental exploration; transferable not pay for the game, with one mother citing that she’d rather real-world skills were learned through parenting statement “research for free versus paying for something that I feel I....can selection. Self-efficacy was experienced through personal gain for free”. success in winning the game and expressed by vocalized interest When asked for a rating of “hated it, didn’t like it, liked it, or in trying new methods at home. Intrinsic motivation for selecting loved it” most mothers (13/20, 65%) said they liked the game. effective vegetable parenting practices was enhanced through Three mothers did not like the game. Four mothers said that motivational messages tailored to parent-selected value they loved it, “because it was educational and it was fun. And statements. All these findings support the likelihood that it kept my attention”. Mommio will influence behavior change. Mothers who did not say that they “loved” the game were asked Repeated testing of an evolving serious game is valuable. Many what could be changed to make them love it. Suggestions earlier findings were supported, strengthening their original included expanding the game across contexts and functionalities import. Differences between the studies demonstrated that game (as discussed in the question about game expansion). Mothers has evolved in an effective way. Several changes will be made also requested clarification of game goals/objective, perhaps to address issues raised (Textbox 2). Trouble with mechanics through the use of a tutorial, as well as improvement to game will be resolved through the discarding of the thumb stick in navigation by modifying the thumb stick feature. More things favor of finger-sweep controls. A tutorial level and more overt to do in the kitchen, such as picking up pantry items or cooking Kiddio expressions will be added to address confusion with were requested. Mothers also felt additional recipes and these game elements. http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al Textbox 2. Directives for future changes to Kiddio. Change or delete onscreen circle thumb stick feature Expand game across additional levels and contexts Expand recipes Add more recipes Add “send to email” feature Keep nutrition panel with carbs, fat, sodium, protein, calories and portion size Add a tutorial level Add feedback, occurring at the end of each game, in the app itself, that includes parenting tips Add more interaction to kitchen items, such as ability to select food from the cabinets Add a broader range of Kiddio facial expressions, especially for mealtime interactions Add more customization of the child character’s physical appearance (clothes, hair) Keep tone/expression mechanic and selectable statement variety Keep value statement, but add a sentence for more context Either replace “spiritual” answer or add many more selectable values that add balance Increased customization of player experience was desired. This Both samples wanted feedback and tips, thus feedback will will be addressed by adding more options to modify Kiddio, become more detailed in future versions of the game. Current such as hairstyles, and more ways to interact with the kitchen. positively evaluated features included selectable statements, Mommio’s new features, such as inclusion of recipes and more voice tone selection, and value statements, which will be kept environment interactions, were well received. Thus, recipes will in future versions of Mommio. However, the mechanic for be increased in number and detail, and made available for home selecting values may evolve. use. Mothers liked the idea of expanding the game, and reported This study’s limitations include a small sample, and only one expansion would increase their desire to play. The final Mommio game quest of one episode of the game was tested. 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Appetite 2013 Oct;69:89-93 [FREE Full text] [doi: 10.1016/j.appet.2013.05.015] [Medline: 23727397] 10. Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall; 1986. 11. Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol 2000 Jan;55(1):68-78. [Medline: 11392867] 12. Thompson D, Baranowski T, Buday R. Conceptual model for the design of a serious video game promoting self-management among youth with type 1 diabetes. J Diabetes Sci Technol 2010 May;4(3):744-749 [FREE Full text] [Medline: 20513343] 13. O'Connor TM, Watson K, Hughes SO, Beltran A, Hingle M, Baranowski JC, et al. Health professionals' and dietetics practitioners' perceived effectiveness of fruit and vegetable parenting practices across six countries. J Am Diet Assoc 2010 Jul;110(7):1065-1071. [doi: 10.1016/j.jada.2010.04.003] [Medline: 20630164] 14. Beltran A, O'Connor T, Hughes SO, Baranowski J, Nicklas TA, Thompson D, et al. Alpha test of a videogame to increase children's vegetable consumption. Games Health J 2012 Jun;1(3):219-222 [FREE Full text] [doi: 10.1089/g4h.2011.0027] [Medline: 24761315] 15. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006 Jan;3(2):77-101. [doi: 10.1191/1478088706qp063oa] 16. Sleddens Ester F C, Hughes SO, O'Connor TM, Beltran A, Baranowski JC, Nicklas TA, et al. The Children's Behavior Questionnaire very short scale: psychometric properties and development of a one-item temperament scale. Psychol Rep 2012 Feb;110(1):197-217. [doi: 10.2466/08.10.21.PR0.110.1.197-217] [Medline: 22489386] Edited by G Eysenbach; submitted 02.12.14; peer-reviewed by P Krebs, A Viggiano; comments to author 06.04.15; accepted 27.04.15; published 24.07.15 Please cite as: Brand L, Beltran A, Buday R, Hughes S, O'Connor T, Baranowski J, Dadabhoy HR, Diep CS, Baranowski T JMIR Serious Games 2015;3(2):e6 URL: http://games.jmir.org/2015/2/e6/ doi: 10.2196/games.4081 PMID: 26208899 ©Leah Brand, Alicia Beltran, Richard Buday, Sheryl Hughes, Teresia O'Connor, Janice Baranowski, Hafza R Dadabhoy, Cassandra S Diep, Tom Baranowski. Originally published in JMIR Serious Games (http://games.jmir.org), 24.07.2015. 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/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 10 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Training Vegetable Parenting Practices Through a Mobile Game: Iterative Qualitative Alpha Test

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JMIR Publications
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Copyright © The Author(s). Licensed under Creative Commons Attribution cc-by 4.0
ISSN
2291-9279
DOI
10.2196/games.4081
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Abstract

Background: Vegetable consumption protects against chronic diseases, but many young children do not eat vegetables. One quest within the mobile application Mommio was developed to train mothers of preschoolers in effective vegetable parenting practices, or ways to approach getting their child to eat and enjoy vegetables. A much earlier version of the game, then called Kiddio, was alpha tested previously, but the game has since evolved in key ways. Objective: The purpose of this research was to alpha test the first quest, substantiate earlier findings and obtain feedback on new game features to develop an effective, compelling parenting game. Methods: Mothers of preschool children (n=20) played a single quest of Mommio 2 to 4 times, immediately after which a semi-structured interview about their experience was completed. Interviews were transcribed and double coded using thematic analysis methods. Results: Mothers generally liked the game, finding it realistic and engaging. Some participants had difficulties with mechanics for moving around the 3-D environment. Tips and hints were well received, and further expansion and customization were desired. Conclusions: Earlier findings were supported, though Mommio players reported more enjoyment than Kiddio players. Continued development will include more user-friendly mechanics, customization, opportunities for environment interaction, and food parenting scenarios. (JMIR Serious Games 2015;3(2):e6) doi: 10.2196/games.4081 KEYWORDS mobile games; games for health; serious games; pediatric nutrition; parenting Because traditional interventions to increase child vegetable Introduction intake have had little or no effect [7], innovative approaches are needed. Serious games provide a behavioral intervention Vegetable consumption is protective against several chronic opportunity to increase child vegetable intake, which has had diseases [1,2]. Children’s dietary practices tend to track into a positive impact on health-related behavior change [8]. A adulthood [3], and parents play an important role in establishing mobile game, Mommio, designed to teach parents of young healthy dietary habits in their young children [4], but often children about vegetable parenting practices [9] is currently report difficulty getting their child to eat vegetables [5,6]. under development. Games for health predicated on a combination of social cognitive [10] and self-determination http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al theories [11] are believed to increase likely effectiveness in Game Description promoting behavior change. According to social cognitive Mommio is a first-person role playing video game that simulates theory, a game that provides a player with relevant knowledge, a mother interacting with her preschool age child (called skills, self-efficacy, and motivation is likely to result in behavior “Kiddio”). Kiddio hates veggies. Players can customize their change [12]. In self-determination theory, personal values are Kiddio’s name, gender, skin, and hair color. The game takes an aspect of relatedness; fulfilling values should increase place in a 3D world that includes the player’s virtual house, intrinsic motivation [12]. In Mommio, targeted desired behavior complete with working kitchen and numerous common includes use of appropriate vegetable parenting practices [13]. distractions, such as a begging family dog and booming A recent meta-analysis revealed that games were most likely to televisions. The player navigates by double-tapping the ground contribute to learning and behavior change when end users were to move inside the world and using an onscreen thumb stick to involved as testers of game mechanics (A. DeSmet, written change perspective. Single tapping a character (Kiddio or the communication, January, 2015). The purpose of this alpha test dog) or a game object (refrigerator, food item, etc.) starts an was to obtain feedback from mothers of preschoolers on interaction. At mealtime, Kiddio prompts the player to action Mommio game mechanics at an early stage when changes could by exclaiming “I’m hungry.” The player must then select a still be made. vegetable recipe from the kitchen’s recipe box as a side dish for lunch. The recipe box features simple recipes for a variety A prototype version of Mommio, Kiddio, was tested by mothers of vegetables, and non-veggie recipes (eg macaroni and cheese) who were similarly interviewed about their experience [14]. which result in a loss if selected. Once the player and Kiddio Substantial changes (eg 3D environment replacing a 2D are seated at the kitchen table, the player tries to get Kiddio to environment, enhanced recipe selections, additional interactive eat the vegetable, and Kiddio refuses. items) were made. The current alpha test (ie testing game features when changes can still be made) of one Mommio quest Mommio is not an easy game to win. The player can try different was to reaffirm conclusions drawn from Kiddio testing [14], as food parenting strategies, such as choosing from effective and well as obtain feedback on new, more sophisticated features to ineffective statements to say to Kiddio, or modifying the produce an effective game that trains vegetable parenting environment (eg turning off the television). The variety of practices among mothers of young (3-5 year old) children. statements that can be selected to say to Kiddio could be modified by voice tone (gentle, firm, or harsh) and facial Methods expressions (happy, neutral, concerned, or angry). If the player makes an effective move, she comes closer to winning the game. Sample and Recruitment If she selects ineffective ways for dealing with the child, she Mothers of 3-5 year old children were recruited after obtaining moves toward losing the game. At the conclusion of each approval from the Baylor College of Medicine’s Institutional Mommio quest, Kiddio either tastes the vegetable to signify a Review Board. Mothers who reported no difficulty getting their victory, or runs out of the room, indicating a loss. child to eat vegetables or were not 20-40 years old were At the conclusion of the quest, players are led through a series excluded. Recruiting took place through digital and printed of screens that asks them to select a parenting value that is flyers distributed throughout the Texas Medical Center, and important to them, from which tailored motivational messages from the Children’s Nutrition Research Center’s volunteer list. will be delivered, as well as a plan for strategies to use at home All mothers (n=20, demographics described in Table 1) provided to increase vegetable consumption based on the selected value. informed consent. http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al Table 1. Demographics.  Demographics n (%) Child Gender Boy 13 (65%) Girl 7 (35%) Highest Education Completed High School graduate or GED 1 (5%) Technical school 2 (10%) Some college 7 (35%) College graduate 5 (25%) Post Graduate Study 5 (25%) Annual Household Income Less than $30,000 4 (20%) $30,000 to $60,000 8 (40%) Over $60,000 8 (40%) Ethnicity Hispanic 9 (45%) African American 6 (30%) White 3 (15%) Asian-Non Vietnamese 1 (5%) American Indian 1 (5%) Employed Yes 14 (70%) No 6 (30%) Primary Responsibility for Feeding the Selected Child Me 13 (65%) Shared among multiple people 7 (35%) Marital Status Married or living with a significant other 13 (65%) Single, Never married 6 (30%) Divorced. Separated, or Widowed 1 (5%) provided a player tutorial guide upon starting their game session, Procedures and were encouraged to ask questions. The interview contained Mothers scheduled one hour time slots at their convenience to 27 questions, with additional probes and prompts (Textbox 1). play Mommio on an Apple iPad tablet under researcher At the conclusion of the interview, participants were thanked observation. Qualitative interviews about their experience and compensated $25. followed, conducted by a trained interviewer. Participants were http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al Textbox 1. Interview questions. 1. What do you think the game is about? 2. What, if anything, did you like about playing the game? 3. What, if anything, did you not like about playing the game? 4. What do you think about the name of the game? 5. What did you think about personalizing the child character? 6. What did you think about being able to pick different things to say to the child character? 7. What did you think about the child character’s reactions to your statements? 8. What did you think about being able to choose recipes to offer the child character? 9. What things did you do in the in the game that you could use with your own child? 10. What did you think about the artwork or graphics for the game? 11. What did you think about moving around the house? 12. What did you think about interacting with items in the game environment? 13. How do you think you can win this game? 14. What did you think about the possibility of game points? 15. What do you think about receiving feedback at the end of gameplay? 16. What did you think about the game’s question about “What is most important to you”? 17. What did you think about the “most important to you” choices offered? 18. What are your thoughts on receiving tips to practice at home? 19. What did you think about having a website as an additional resource? 20. Today you played the “lunch” level of the game. The finished game will include other situations like car trips, dinners, grocery stores, and fast food restaurants. Would you play a game like this? 21. Do you read nutrition labels while at home or in the grocery store? 22. If the game was a free app game how likely would you download it to play? 23. How much would you be willing to pay for this app game? 24. If you had to pay for this app game, how likely would you download it to play? 25. On a scale of 1 to 3, where 1 is “not difficult” and 3 is “very difficult,” how difficult is it to get your child to eat vegetables? 26. Using a 1 to 4 STAR rating scale, how would you rate the game? 27. Before we finish, is there anything else you want to tell me that you haven’t had an opportunity to say? A majority of the sample (12/20, 60%) found navigating the Data Analysis game environment frustrating. This was largely due to the thumb Interviews were audio-recorded and transcribed in full. All stick, which was felt to be “overly sensitive” and “very hard transcriptions were double-checked against the original to control” (see Figure 1). Over half of the mothers (12/20, recording before importing into NVivo (Version 10.0, 2012, 60%) found the circle thumb stick difficult to use, and a few Doncaster, VIC, Australia). Thematic analysis [15] was used (2/20, 10%) found the feature to be a deterrent to engagement. to code each response within the questions posed. Transcripts For some (6/20, 30%), the thumb stick mechanic was a learning were double coded to ensure reliability. Differences between curve that “took me a while to get accustomed to.” A handful coders were adjudicated by discussion and consensus. of mothers (3/20, 15%) suggested using direction arrows instead of or in conjunction with the thumb stick, or to maneuver by Results dragging “not the circle, just with your finger.” Less than a quarter of mothers (4/20, 20%) mentioned liking the thumb Game Elements stick feature. Most mothers completed three iterations of the game. On Nearly all mothers (19/20, 95%) enjoyed the ability to average, gameplay consumed 20 (SD 7) minutes. Patterns personalize the look of the child character, although some (5/20, emerged in regard to the design of the Mommio game. These 25%) wanted more hair options while others (7/20, 35%) wanted themes reflected on game look and feel, as well as mechanics more clothing options, which “would feel more like it’s my not related to vegetable parenting. child.” Nearly all participants (19/20, 95%) enjoyed naming the character after their own child, which increased the realism http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al of the story. A majority of participants (16/20, 80%) would have I did try to get a box of something off one of the liked to pick the child’s personality (ie temperament [16]) in cabinets, but that didn’t work either. So just having the game, as this would be the option would be good. Many participants liked interacting with the environment in more realistic to what parents or guardians have to other ways, such as turning off the television (9/20, 45%) and deal with when they’re trying to encourage a kid with speaking to the dog (5/20, 25%), which increased the realism a certain type of personality to eat their vegetables, of the environments and was “something extra to do…it was because all kids are not the same. neat”. The main action of the game took place in the kitchen of the home. Perhaps due to this, nearly half of the mothers (8/20, Three quarters of participants said that they liked the graphics 40%) were not aware that the navigable 3D environment and looks of the game. About one third of all parents thought included the entire house and yard. This was reflected in that the home and kitchen looked modern or realistic (6/20, comments such as 30%), liked the bright colors used (5/20, 25%), and thought that the art looked professional (5/20, 25%); though a minority I wish we would have been able to move more around mentioned (2/20, 10%) that the art looked like cartoons tailored the house to make it a little interesting for preschoolers. A few participants (3/20, 15%) thought the and art was passable, but unremarkable, such that they were I didn't try to go out past the kitchen. But I'm sure not sure it would win awards necessarily, in terms of that's the only place you'll be able to go its, like, graphic ability, but it was totally fine. Most (16/20, 80%) thought that double tapping the floor to The kitchen and home environment were noted as “nice and move in the environment was either good or fine. Four mothers cute” and about a quarter of participants (4/20, 20%) mentioned thought this countered some of the difficulty experienced with enjoying exploring and interacting with the realistic kitchen, the thumb stick feature, saying “I thought that made it easier, which was stocked with grocery items. a lot easier”. All mothers agreed receiving feedback at the end of gameplay However, a few (3/20, 15%) mothers did not understand or use would be beneficial. The majority (13/20, 65%) thought that this feature. feedback should occur at the end of each episode (level), although a few (3/20, 15%) thought that it should occur after a Thirteen mothers liked interacting with items in the game few episodes taking place in one sitting. The most commonly environment, with 25% (5/20) mentioning that this feature made preferred method of delivery was in-app, followed by email. the game more realistic. However, three mothers were Common requests for feedback content included points earned, unclear whether doing any of those things has any quality of food choices made, tips to improve gameplay, and impact on the game, like turning off the TV. Is it evaluations of parenting statements selected. Some participants important to do that as part of the process or are these (7/20, 35%) wanted to see a tie-in to the learning goals of the just things that are there for no particular reason? game through feedback, All participants opened and closed cupboards in the kitchen because if I’m going to take time to play the game, environment, and 35% (7/20) enjoyed seeing the contents of then I would want to receive something from it the kitchen and nutrition labels of food. Almost half of all beneficial that I could use. participants (9/20, 45%) wanted more available interactions with items in the kitchen, saying things such as Figure 1. Joystick mechanic. http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al All but one mother found the child’s reactions helpful in Learning Content knowing how well they were doing in the game, as “you can For the video game to be effective, it must adequately express read by the facial expressions” The mother who did not find and incorporate vegetable parenting messages. Several themes the child character’s reactions helpful cited a lack of variation were found from participant discussion of learning content. in expression, similar to the reasons for the child character’s All mothers enjoyed being able to select statements to say to unexpected reactions. Kiddio and found the available statements realistic (see Figure Upon first playing, game goals and objectives were unclear to 2). Several (6/20, 30%) mentioned the variety of statements many participants. Some (8/20, 40%) “had no clue what to do,” available to them, which which resulted in confusion or frustration. Mothers who was great because there were some things I wouldn't expressed this either consulted the provided user guide or asked necessarily say to my child. But I found something the researcher for help before making strides in game that fit me and my personality on how I would respond progression. in the situation. Most mothers (19/20, 95%) liked the vegetable recipes provided Others (4/20, 20%) thought the selectable statements were through the in-game recipe box and that recipes included limited and should be expanded to not get repetitive in future instructions and nutrition information. Some (8/20, 40%) pointed levels. out real-world benefits for including this information, and that the recipes may Every mother interviewed found statements that she would use or has used with her own child. Most commonly mentioned help me to learn like what's healthy, what's not statement types noted as effective in the game were healthy. I guess it's going to be good for kids as well. encouragement to try a vegetable or take a few bites and trying The vast majority of mothers (18/20, 90%) said they would be or preparing vegetables with the child. The most frequently interested in using the recipes at home with their own child, or mentioned ineffective strategies were bribing with food or already do. Nearly all mothers (18/20, 90%) said they would activities after eating and telling the child that he should sit at be interested in learning how to make the recipes at home. A the table until he eats his vegetables. minority of mothers (2/20, 10%) found the recipes too simple Many players thought that the child character’s reactions were and thus already knew how to make them. realistic (17/20, 85%) and similar to their own child (15/20, Almost half of mothers (9/20, 45%) would prefer to receive 75%). A few mothers mentioned liking the character’s realistic game recipes though an in-game recipe box with an option to attachment to a favorite toy (3/20, 15%), as well as Kiddio’s select individual recipes to send to their email. Other preferences responses to player actions. Many (8/20, 40%) pointed out included only the in-game recipe box, a combination of email differences between the child character and their own child, and website, featured in the app but outside of gameplay, and including differences in stubbornness (3/20, 15%) (the child on a website. Frequent responses to ideal recipe content, aside character was perceived as both more and less stubborn than a from ingredients, included calorie count, instructions, nutrition parent’s own child), responses to bribery (2/20, 10%) (the content, and serving size. character does not respond well to bribery, real child does), and activity level (4/20, 20%) (own child talks and fidgets more, Nearly half of all participants (9/20, 45%) thought the player including eating items on plate to avoid vegetables). wins the game by getting Kiddio to eat vegetables. Several additional mothers focused on the parenting strategies as ways While a large majority of mothers (17/20, 85%) thought Kiddio to win, such as watching one’s tone while speaking (6/20, 30%), responded mostly as expected, three participants found that selecting the right parenting statement (4/20, 20%), and using there was not enough variation of child animations to portray generally effective communication strategies (2/20, 10%). Three appropriate reactions, as mothers did not mention parenting strategies, but indicated that it seemed as if it was always stuck on a certain, ‘I picking healthy foods was the way to win. don’t want it, I don’t want to do it’ kind of look. http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al Figure 2. Playing a meal. The mother who disagreed thought that a game was not the best Real World Application format for receiving parenting tips. Preferred methods of A series of questions asked participants to reflect on personal parenting tip delivery and scheduling time to practice were values regarding parenting practices. This included a game email, electronic calendar app or other mobile scheduling prompt, which asked participants to practice vegetable parenting program, in-game only, and text message. based on a parent-selected value. Participants generally were All participants indicated at least one food parenting practice open to a real-life crossover, given their current values and from the game they either had used in the past with their own habits. child or would use in the future. Popular responses include being A game storyboard featured a question asking players to select aware of vocal tonality or facial expressions when speaking to what value (e.g. being a role model, being spiritual) was most the child (see Figure 2), staying positive or encouraging, sitting important to them given multiple options. Half of all mothers down at the table with the child for meals, role modeling healthy interviewed (n=10) thought this question was good or okay. habits, choosing healthy vegetable recipes, involving one’s child However, six mothers found it confusing, commenting “I didn’t in the meal preparation process, and general communication relate this to the game really,” and “I wasn't really sure of strategies. exactly what the point was there”. The vast majority (17/20, Fourteen mothers reported reading nutrition labels in the grocery 85%) understood the question, although two mentioned they store. Those who read labels used the information because they needed more context to understand what the question was wanted to feed their child healthy foods, prevent disease related asking. to unhealthy eating, be aware of what is in their food, make A quarter of participants (5/20, 25%) found selectable value choices between similar products, and limit certain nutrition options to be good or okay. A handful of mothers (4/20, 20%) elements, such as sugar. agreed that When reading nutrition labels, mothers said they looked for being spiritual-even though it may be important to numbers for sugar or carbohydrates, calories, sodium, fat, you, but I think it’s just so far and apart from the protein, and portion size. Five mothers reported looking at game ingredient lists in addition to nutrition panels. Several of these components were listed on nutrition labels provided for each and would have liked to see this value replaced with something recipe in the game. About half of mothers interviewed (11/20, that fits better with the game and other available options. Most 55%) thought all recipes in the game should have these nutrition (15/20, 75%) said the selectable options made sense to them, panels, and even more (14/20, 70%) wanted to see the but a couple said they were not sure how to answer given ingredients of a recipe in the recipe box before making a provided choices. All mothers interviewed thought at least one selection. of the listed values applied to them, though five would have liked to select more than one value. Future Production All mothers indicated they would be willing to try out game Evaluations of the game as a whole and thoughts about its future tips with their own child, largely willing to consider parenting were presented over the course of each interview. More than practices that could help with their parenting, saying “if you half of mothers interviewed (13/20, 65%) thought that a can get advice and help from others, it's always a plus”. All but companion website would be good or helpful. Mothers suggested one mother agreed that receiving tips to practice at home would the website include recipes with nutrition tips, parenting tips, be helpful, as forums or user generated content, links to external resources, and the game itself. it helps that you have those tips and that you've practiced, and you have some information under your A larger, more complex game that featured several mealtime belt and ready. contexts was of interest to a large majority of mothers (17/20, http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al 85%). Those interested in playing said that variety would make feedback after gameplay would make the game better, as well the game more interesting and would be helpful delivering as the addition of audio. parenting tips for different scenarios. A few mothers (3/20, 15%) mentioned wanting grocery store help specifically, while Discussion a few others (2/20, 10%) mentioned tips for car trip food Results were generally consistent with earlier findings [14]. parenting. Both studies uncovered initial confusion by players about the All but one mother said a game that varied in context would game’s objective, but understanding of the game’s primary goal seem more like their real life. One mother said that it would after at least one level was played [14]. Mechanics and not, due to the fact that nearly all meals her family consumed navigation were considered difficult in both studies [14], were in the home. although they had been modified after the earlier test. Customization was appealing for both the child character as Most mothers (15/20, 75%) said they would likely play multiple was the ability to choose what to say and do in the game meals in a row in the proposed expanded version of the game. environment [14]. Feedback was a desirable in-app feature Those who mentioned not wanting to do this commented that across both studies, as was Kiddio’s animations and reactions, “trying to remember too much at the same time is not going to though both samples suggested ways they could be improved be effective, either,” and that playing the game in small chunks [14]. Both studies found that while asking players to choose a would let them retain tips and information for future use. value was fine, mothers had a difficult time selecting only one When asked how likely they would be to download the game parenting value given the options displayed, though these if it were free, the large majority of mothers (17/20, 85%) said options were different in form and number for each study [14]. that they would very likely do so. Reasons included it “would Some findings between Kiddio and Mommio differed [14], be beneficial” or useful to parenting, that the game supports perhaps due to enhancements in the game itself. Mommio interactive time with one’s own child if they play together, and participants rated the game higher; with more saying they curiosity. Two mothers who would not download the game for “loved” the game [14]. Many more Mommio than Kiddio players free reported not liking any types of games, and the remaining were interested in playing the game if it were free or if it had a mother was not sure whether or not she would download the small cost, suggesting the changes made enhanced its appeal. game until it was expanded further. Aspects of social cognitive and self-determination theories were Two mothers reported being slightly less likely to download endorsed. Participants reported gaining knowledge through the game if they had to pay for it than if it was free. Three would situated learning and environmental exploration; transferable not pay for the game, with one mother citing that she’d rather real-world skills were learned through parenting statement “research for free versus paying for something that I feel I....can selection. Self-efficacy was experienced through personal gain for free”. success in winning the game and expressed by vocalized interest When asked for a rating of “hated it, didn’t like it, liked it, or in trying new methods at home. Intrinsic motivation for selecting loved it” most mothers (13/20, 65%) said they liked the game. effective vegetable parenting practices was enhanced through Three mothers did not like the game. Four mothers said that motivational messages tailored to parent-selected value they loved it, “because it was educational and it was fun. And statements. All these findings support the likelihood that it kept my attention”. Mommio will influence behavior change. Mothers who did not say that they “loved” the game were asked Repeated testing of an evolving serious game is valuable. Many what could be changed to make them love it. Suggestions earlier findings were supported, strengthening their original included expanding the game across contexts and functionalities import. Differences between the studies demonstrated that game (as discussed in the question about game expansion). Mothers has evolved in an effective way. Several changes will be made also requested clarification of game goals/objective, perhaps to address issues raised (Textbox 2). Trouble with mechanics through the use of a tutorial, as well as improvement to game will be resolved through the discarding of the thumb stick in navigation by modifying the thumb stick feature. More things favor of finger-sweep controls. A tutorial level and more overt to do in the kitchen, such as picking up pantry items or cooking Kiddio expressions will be added to address confusion with were requested. Mothers also felt additional recipes and these game elements. http://games.jmir.org/2015/2/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brand et al Textbox 2. Directives for future changes to Kiddio. Change or delete onscreen circle thumb stick feature Expand game across additional levels and contexts Expand recipes Add more recipes Add “send to email” feature Keep nutrition panel with carbs, fat, sodium, protein, calories and portion size Add a tutorial level Add feedback, occurring at the end of each game, in the app itself, that includes parenting tips Add more interaction to kitchen items, such as ability to select food from the cabinets Add a broader range of Kiddio facial expressions, especially for mealtime interactions Add more customization of the child character’s physical appearance (clothes, hair) Keep tone/expression mechanic and selectable statement variety Keep value statement, but add a sentence for more context Either replace “spiritual” answer or add many more selectable values that add balance Increased customization of player experience was desired. This Both samples wanted feedback and tips, thus feedback will will be addressed by adding more options to modify Kiddio, become more detailed in future versions of the game. Current such as hairstyles, and more ways to interact with the kitchen. positively evaluated features included selectable statements, Mommio’s new features, such as inclusion of recipes and more voice tone selection, and value statements, which will be kept environment interactions, were well received. Thus, recipes will in future versions of Mommio. However, the mechanic for be increased in number and detail, and made available for home selecting values may evolve. use. Mothers liked the idea of expanding the game, and reported This study’s limitations include a small sample, and only one expansion would increase their desire to play. The final Mommio game quest of one episode of the game was tested. The game game will expand across environments such as the car and was presented on a tablet, which was familiar to some, but not grocery store. to others, and may have served as a barrier to engagement. Acknowledgments This research was made possible in part by SBIR funding from the US Eunice Kennedy Shriver National Institute of Child Health and Human Development by grant R44HD075521, and institutional support from the US Department of Agriculture, Agricultural Research Service (Cooperative Agreement 58-6250-0-008). Conflicts of Interest Richard Buday, President of Archimage, is the commercial developer of the Kiddio and Mommio video games. References 1. Andres S, Abraham K, Appel KE, Lampen A. Risks and benefits of dietary isoflavones for cancer. Crit Rev Toxicol 2011 Jul;41(6):463-506. [doi: 10.3109/10408444.2010.541900] [Medline: 21438720] 2. Boeing H, Bechthold A, Bub A, Ellinger S, Haller D, Kroke A, et al. 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[doi: 10.2466/08.10.21.PR0.110.1.197-217] [Medline: 22489386] Edited by G Eysenbach; submitted 02.12.14; peer-reviewed by P Krebs, A Viggiano; comments to author 06.04.15; accepted 27.04.15; published 24.07.15 Please cite as: Brand L, Beltran A, Buday R, Hughes S, O'Connor T, Baranowski J, Dadabhoy HR, Diep CS, Baranowski T JMIR Serious Games 2015;3(2):e6 URL: http://games.jmir.org/2015/2/e6/ doi: 10.2196/games.4081 PMID: 26208899 ©Leah Brand, Alicia Beltran, Richard Buday, Sheryl Hughes, Teresia O'Connor, Janice Baranowski, Hafza R Dadabhoy, Cassandra S Diep, Tom Baranowski. Originally published in JMIR Serious Games (http://games.jmir.org), 24.07.2015. 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/e6/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e6 | p. 10 (page number not for citation purposes) XSL FO RenderX

Journal

JMIR Serious GamesJMIR Publications

Published: Jul 24, 2015

Keywords: mobile games; games for health; serious games; pediatric nutrition; parenting

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