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User-Centered Design of Serious Games for Older Adults Following 3 Years of Experience With Exergames for Seniors: A Study Design

User-Centered Design of Serious Games for Older Adults Following 3 Years of Experience With... Background: Seniors need sufficient balance and strength to manage in daily life, and sufficient physical activity is required to achieve and maintain these abilities. This can be a challenge, but fun and motivational exergames can be of help. However, most commercial games are not suited for this age group for several reasons. Many usability studies and user-centered design (UCD) protocols have been developed and applied, but to the best of our knowledge none of them are focusing on seniors’ use of games for physical activity. In GameUp, a European cofunded project, some prototype Kinect exergames to enhance the mobility of seniors were developed in a user-centered approach. Objective: In this paper we aim to record lessons learned in 3 years of experience with exergames for seniors, considering both the needs of older adults regarding user-centered development of exergames and participation in UCD. We also provide a UCD protocol for exergames tailored to senior needs. Methods: An initial UCD protocol was formed based on literature of previous research outcomes. Senior users participated in UCD following the initial protocol. The users formed a steady group that met every second week for 3 years to play exergames and participate in the UCD during the 4 phases of the protocol. Several methods were applied in the 4 different phases of the UCD protocol; the most important methods were structured and semistructured interviews, observations, and group discussions. Results: A total of 16 seniors with an average age above 80 years participated for 3 years in UCD in order to develop the GameUp exergames. As a result of the lessons learned by applying the different methodologies of the UCD protocol, we propose an adjusted UCD protocol providing explanations on how it should be applied for seniors as users. Questionnaires should be turned into semistructured and structured interviews while user consultation sessions should be repeated with the same theme to ensure that the UCD methods produce a valid outcome. By first following the initial and gradually the adjusted UCD protocol, the project resulted in exergame functionalities and interface features for seniors. Conclusions: The main lessons learned during 3 years of experience with exergames for seniors applying UCD are that devoting time to seniors is a key element of success so that trust can be gained, communication can be established, and users’ opinions can be recorded. All different game elements should be taken into consideration during the design of exergames for seniors even if they seem obvious. Despite the limitations of this study, one might argue that it provides a best practice guide to the development of serious games for physical activity targeting seniors. (JMIR Serious Games 2017;5(1):e2) doi: 10.2196/games.6254 http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al KEYWORDS user studies; usability testing; gestural input; user-centred design; accessibility; consumer health; exergames; participatory design; lessons learned Why a Unique Design for Seniors? Introduction It has been established in several studies that seniors enjoy Overview playing exergames and they believe exergames can assist in maintaining physical activity [7-12]. Despite the fact that Physical activity is important at all ages, and seniors particularly balance and rehabilitation of seniors can be maintained and need sufficient strength, balance, and flexibility to manage in improved through exergames [2,3,7,8,13-16], not many are everyday life. This is particularly true for those ages 65 years designed for this age group [11,17,18]. Game designers use and older. their creativity for game ideas, but since designers normally are Exergames can be a method to motivate seniors to exercise and young, they do not often consider the needs of seniors [19]. The hence get more physical activity with sufficient physical exertion game stories might therefore not be of interest for the senior [1]. Most commercial games are, however, not suited for this population. group for several reasons including speed, amount of A trial using Nintendo Wii exergames for seniors indicated that information, required movements, etc [2-4]. age-related impairments influence the use of video games among GameUp, a project cofunded by the European Union, Spain, frail elderly, so this should also be considered in the design Norway, and Switzerland [5,6] aimed at creating useful and process [20]. We have indeed observed that there are many motivational exergames for seniors, was undertaken with a obstacles for seniors playing commercial exergames, and this user-centered approach during the design and development has been confirmed in other studies [4,7]. Also, existing games process to meet the users’ limitations and requirements. for the young are not developed to meet the physical exercise needs of elderly people. Based on these findings we can Despite the fact that many usability studies and user-centered conclude that good and safe exergames should be developed design (UCD) protocols have been developed, to the best of our particularly for seniors, both regarding movements and narrative. knowledge none of them have focused on seniors’ use of games for physical activity (ie, exergames). Furthermore, there is What Is User-Centered Design? limited information regarding the design and functionality of The International Organization for Standardization uses the serious games for seniors and more specifically for exergames. term “human-centered design” and defines it to be an “approach An initial UCD protocol was created based on literature and to systems design and development that aims to make interactive previous research outcomes in order to develop the GameUp systems more usable by focusing on the use of the system and project exergames. During the project, we followed that protocol applying human factors/ergonomics and usability knowledge and adjusted it based on 3 years’ experience in order to meet and techniques” [21]. The same standard also states that this the needs of both the project and the users. In this paper we term in practice is used synonymously with UCD. According report the lessons learned for the different phases of the protocol to Karat and Karat [22], “UCD defines iterative processes whose and the adjustments that our initial protocol needed in order to goal is the development of usable systems.” According to Sebe be applicable to older adults and we highlight the most important [23], “user-centered design (UCD) is a process (not restricted UCD influences and recommendations on the GameUp to interfaces or technologies) in which the needs, wants, and exergames. limitations of end users of a product, service, or process are The remainder of the paper is structured as follows. Initially, given extensive attention at each stage of the design process. we set the scene by pinpointing the need for unique design for UCD can be characterized as a multistage problem-solving seniors, exploring the UCD, and identifying the need for a process that not only requires designers to analyze and foresee specific UCD for seniors. In the Methods section we describe how users are likely to use a product but also to test the validity all the necessary elements of lessons learned, namely the UCD of their assumptions with regard to user behavior in real world protocol which served as the base of our exergames tests with actual users.” implementation, the recruitment criteria for the seniors, the Since UCD can be considered a multistage process, one will GameUp exergames, and the considered ethical aspects and normally use different methods in different stages. Both risks. Next, the Results section describes the lessons learned qualitative and quantitative methods were used by Proffitt and from a 3-point view: (1) the lessons learned during the different Lange [24] while implementing a UCD. They used focus groups protocol phases, (2) changes and tips for our initial protocol on as well as an iterative user-testing process while testing changes the different methodologies of the UCD protocol, and (3) the to a prototype. One study [25] used a 3-stage qualitative UCD lessons learned from the important changes of our developed approach in the requirement phase including literature search exergames. The Results section points out the initial protocol’s and focus groups. The actual use of UCD in the industry was weaknesses against the existing literature including the studied by Vredenburg et al [26] wherein 13 methods were limitations of our approach. Finally, the Conclusions section identified, among them field studies, user requirements analyses, sums up the lessons learned and emphasizes the key issues on iterative design, usability evaluation, task analyses, focus groups, applying UCD with seniors. user interviews, participatory design, and prototypes. Several of these methods have been used in our initial protocol. http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al be flexible on timing to maintain participation in a long-term Need for a Specific User-Centered Design for Seniors study. Gregor et al [27] further conclude that UCD principles need to be employed for seniors. Seniors are different from the young; Existing research on Web design for elderly people shows the “functionality, needs, and wants differ from the young even importance of designing and implementing games and though they consider themselves as fit, but many often have applications uniquely targeting elderly people. We have several physical problems with a general reduction in identified some initiatives and research aimed at providing functionalities” [27]. The authors further refer to the difficulty guidelines for the design and accessibility of websites for elderly both of recruiting representatives from this group and of people [32-40]. AgeLight [33] points out the importance of communicating with them. player-centered design, meaning that the seniors should be brought in early in the design process. An affordance-based When users have special needs like the senior users do, the costs approach to designing a game was followed by Awad et al [41] of applying UCD increases as the users have more diverse emphasizing “the type of action the user can perform but also requirements [28]. Zaijcek [29] concluded that it is difficult to when (response times) and how it can be performed (range of arrange traditional focus groups for seniors, which is a common motion).” In this study the authors followed an iterative testing method in UCD. Focus groups should be adapted for older process starting with an early prototype. people, and their organization requires considerable interpersonal skills. They conclude that interface design for Despite the fact that some studies followed a UCD, to the best seniors is more complex than for other groups. of our knowledge none of the studies coded and formed a UCD protocol for exergames targeting seniors. In addition, there are According to Zajicek, “adults as they get older experience a few studies that recorded the needs of the older adults either for wide range of age-related impairments including loss of vision, the creation of exergames or as being part of a UCD. hearing, memory and mobility, the combined effects of which contribute to loss of confidence and difficulties in orientation Methods and absorption of information” [29]. With age, eyesight and hearing deteriorate and seniors require more time to think and Recruitment get an overview [10,30]. Also motoric skills deteriorate with One of the partners in the project was a senior center, and the age, and many seniors have health conditions limiting their participants in the UCD were recruited from its members. In abilities. order to ensure that participants would be available throughout Dickinson et al [31] made a list of guidelines for maximizing the duration of the GameUp project, a regular group was formed the research outcomes of working with older adults. The test that met every second week to play exergames and share a meal. case was to learn to use email, but some of the recommendations Researchers would participate often but not at all gatherings. are also valid for exergame development. One is to put great All testing, interviews, etc, were performed at these gatherings. care into making sure information and instructions are To ensure that the participants were in the target group for the understood; another is that one has to be flexible when it comes GameUp project and also competent to sign an informed to timing during trials. They also point out the difficulties of consent, inclusion and exclusion criteria were defined (Textbox recruitment and the importance of being able to reschedule and 1). Textbox 1. Eligibility criteria. Inclusion criteria: Aged 65 years or older Risk of falling or history of falling Recent illness or surgery Impaired strength or balance Exclusion criteria: Cognitive impairment, defined as a Mini Mental State Examination score below 25 Other disease, illness, or limiting condition that would make inclusion and beneficial use of the system difficult, such as complete blindness, deafness, or severe disabilities on the aforementioned literature and on indications through Definition of a High-Level Protocol for User-Centered previous research engaging seniors and exergames on a much Design of Exergames for Seniors smaller scale [10]. This protocol was then tested during the A high-level protocol for UCD of exergames for seniors was GameUp project on a group of seniors over a 3-year period. A developed by the authors as depicted in Figure 1. This was based description of the design protocol and how it was used follows. http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al Figure 1. The 4 phases and the methods used in each of the phases. exergame with smaller new user groups can also give valuable Phases of Development input. The methods for user involvement in this phase are Requirement Gathering and Analyses • Structured and semistructured interviews The main objective of this phase was to gather requirements • Observations for an initial design by collecting basic requirements and needs • Questionnaires of the end users for the chosen group as well as requirements • Prototype tests with new participants for the games to be developed by defining useful exercises. The The Games methods for the user involvement in this phase included Microsoft Kinect was chosen for development based on usability • Literature study studies [42]. The movements included exercises for balance, • Questionnaire with background information flexibility, and strength, all important for mastering daily • Observations while end users play commercial exergames activities. • Group discussions A total of 7 minigames were developed. The 3 balance games • Existing knowledge in the project group are based on the same concept but with different graphics, and Design thus they appear as different games. In these games, one is In this phase, the initial design of the games become more supposed to catch things that fall from above. The falling items detailed using an iterative approach. The users should have a (apples, stars, and chickens) are of 2 different colors, and they real opportunity to influence the outcome of the design by giving need to be put in the correct basket. In addition, 4 different feedback. This phase includes the following methods for user minigames for leg strength and flexibility were developed. Since involvement: there was a big difference in abilities in the user group, the games have several difficulty levels. • Observations • Semistructured interviews Ethical Aspects and Risks • Group discussions Ethical aspects and risks must be identified, including an exit strategy if the participants are enjoying and even getting Implementation dependent on the GameUp project results. In our case there The implementation phase follows an iterative approach based were no direct medical interventions, but many exercises are on feedback and user reactions. Detailed descriptions of the performed standing, and there could be a risk of falling. Some design may need to be adjusted merging different parts of the can play alone; for others there must either be a person or chair game. During the implementation phase, methods for user for support. Some will even play seated or use a walking frame. involvement are A Berg Balance Scale was performed for all the users before • Observations the start of the UCD to define the appropriate level of exercises. • Semistructured and structured interviews To avoid any further risk, all the participants were informed • Group discussions about proper use of the system. Evaluation The participants have no economic interest or obligations related In the evaluation phase, the emphasis is on the final prototypes. to the GameUp project, and participants hold the right to exit The most common approach is to run pilot tests, but testing the http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al the project at any time without having to provide a reason for Design this and without consequences. Videotaping proved to be useful in order to analyze the reactions of the users to different tests. Furthermore, we identified that Ethical approval for this study was granted by the Data all the different elements should be taken into consideration Protection Official for Research in Norway. during the design of exergames for elderly, including theme, movements, user interface and interaction both with the games Results and the technology, colors, sounds, playability, etc. As explained above, we developed Kinect-based exercises. During the design Study Participants phase, we aimed both to learn how the users reacted to this type Approximately 7 to 10 seniors would be present at each of interface and which of the physiotherapist-defined movements gathering, and they were retirees in the age range of 66 to 95 would be suited for Kinect games. All the different elements years. In total 16 persons participated. were presented progressively to the users. Initially, the first All participants signed an informed consent and were aware of design was presented to the users by presenting graphics on the fact that they were participating in a research project in paper and then the interaction with the system was introduced which a UCD method would be followed to implement the by presenting the physical movements required. Later, design GameUp exergames. During the 3 years, several members left elements like sound and graphics were introduced. the group for various reasons, and new ones were recruited. Implementation Reasons for discontinuation were varied: 1 moved to a care Detailed descriptions of the design were adjusted during this home far away, a couple got too sick to continue, 1 died, and 1 phase since merging different elements of the design required had a steep cognitive decline and could no longer participate. additional user input. Different tests of the exergames were The average age was over 80 years but because of the time span performed using different methods depending on what was and replacements, this was not constant. The first established appropriate: (1) test of early prototypes, (2) iterative tests with group consisted of 9 participants, 1 man and 8 women aged 71 changes according to outcomes from previous tests, (3) tests of to 95 years with an average age of 83 years. Toward the end of user interface elements (coming together), and (4) test of the the GameUp project at the completion of the UCD protocol, playability of the game with focus on game story and game there were 10 participants, 2 men and 8 women in the age range theme. of 66 to 90 years with an average age of 81.7 years. Evaluation Lessons Learned Using User-Centered Design With As part of this phase we tested the final prototype with our Seniors group. We observed that the group that participated throughout the other 3 phases of the UCD protocol provided feedback Lessons Learned During the User-Centered Design during this phase as well, with a few alterations as described in Protocol Phases the Study Participants subsection. Requirement Gathering and Analyses Lessons Learned Applying the User-Centered Design During this phase, a multidisciplinary team should be involved Protocol Methodologies from the beginning. Important inputs for our exergames design Our initial UCD protocol was used throughout the project in a were that physiotherapists defined suitable exercises to help the UCD methodology although it was slightly adjusted to enable mobility of seniors, developers studied the possibilities of the us to reach our goal. The lessons learned could be summed up different tracking movement technologies such as Wii and as a series of tips and adjustments for the creation of serious Kinect, and game designers considered game elements, etc. games for seniors and are summarized in Figure 2. http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al Figure 2. Adjustment to initial protocol for user-centered design (UCD) design having seniors as users. planned, resulting in minimizing both the number of questions Questionnaires in Interviews and the number of answering options and spending more time Questionnaires were part of our initial UCD protocol during on getting useful answers. the “Requirement Gathering and Analyses” and “Evaluation” Semistructured and Structured Interviews phases. In order to apply those to our user group, we realized that we had to adjust them by reducing the questions for each In the semistructured interviews, we had some open questions session because the users found it hard to concentrate for a long and discussions in addition to the structured interviews where period and they got exhausted very quickly. If there were many we wanted to learn about users’ opinions on specific topics. At questions, we would observe very visible signs of fatigue and the beginning of the application of the UCD protocol, we more loss of concentration. or less only got replies to direct questions, which made us think that only structured interviews should be used, but toward the To this extent, we completed all questionnaires in the form of end of the application of the UCD protocol many would give structured or semistructured interviews since many of the their own suggestions and that allowed us to constructively participants had problems both reading and writing and many include semistructured interviews. also had problems understanding some of the questions despite the fact that they met the inclusion and exclusion criteria. Some Observations of the participants also tended to unintentionally skip questions, Researchers often observed the seniors as they played both so the questionnaires have to be short and very clear if used. commercial games and the GameUp project–developed games. In the observations, we could see how they mastered both the When a 5-point Likert scale was used, the facilitators of the game technology and the movements but also how much they session turned the questionnaires into structured interviews as did not perceive. This was particularly the case in many of the explained above. Furthermore, additional time had to be spent commercial games. Based on observations, we also defined on getting a proper reply. For example, a common answer in questions for group discussions and structured interviews about this case was “That is fine” in order to avoid a thorough reply. the project games. For instance, we had the feeling that most Also the way many responded on color tests gave the impression could only see exactly what they were doing in the game even that they wanted to tell there was nothing wrong with their if the graphics were very simple and clear. We therefore asked eyesight instead of telling what they could see the best. Finally whether they could see information on the top of the screen a different approach was taken on the questioning than first http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al about the points earned while they were playing. In fact, nobody and frequently we had to repeat the responses so that all could could see it even though they had been playing the same game hear what had been said. several times as well as watching others play. We also observed Another important lesson learned is that replies would often repeated errors and could adjust the game accordingly. come gradually playing the same game version in several We used observations to see the users’ reactions to the design sessions. Repetitions were also important to get the response elements as well as to detect errors and misunderstandings. from as many as possible, since there were always some who Observations also made us change graphics or parameters: the were not present at specific gatherings. speed of the games or the placement of menu buttons, for As an example of the outcome of group discussion, one theme example. We also made sure that it was possible to get that was successfully discussed was the perceived contents or information before or after gameplay instead of during the game. game story. In one minigame the players perform knee bends, which results in water coming from a pump and into a bucket Group Discussions (Figure 4). Occasionally a cow would pass by and bellow, so The setting of the group discussion was as follows: the entire many players wanted the water to run into a trough for the cows group would sit in a semicircle in front of the screen with the instead of a bucket. Another example is a flexibility game where person playing in front, and they would take turns playing the players use a scythe. Most of the players had used scythes (Figure 3). In between playing or before and after we would in their youth and were a bit frustrated that it was cutting in the initiate small group discussions while all were seated by wrong direction. In the game, the corn was cut when the scythe triggering a discussion through questions about the game, was on the way back, but in reality you have to cut on the first particularly if we had introduced something new. We found the move and then swing the scythe back. setting appropriate since the users didn’t have to change places between observing or playing the game and discussing. Issues Many changes occurred to the developed exergames through we brought up during the group discussions included hearing the 3 years of the GameUp project. We briefly describe the ones issues of the users. Hearing is a problem for many elderly that can be generalized to other games in Figure 5. people; we experienced that we often had to repeat questions Figure 3. Seated in front of the screen ready to play. http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al Figure 4. Bending knees to get water. Figure 5. Most important exergames elements and functionality as resulted from 3 years of experience with exergames for seniors. http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al need to be clear and bright, and users’ feedback helped us Lessons Learned From Exergames Targeting change graphics. Also small details were lost. For instance, the Seniors—Important Changes straw and apple in Figure 6 was perceived as a pipe, so the straw Among the most important elements of the games were speed, was removed. This also means that fonts must be big and clear, both of some movements and of the game progress. In our and there should be as little text as possible, preferably exergames, we needed to reduce the speed of both and in accompanied by oral feedback. Oral information is important, addition adapt the game to the physical ability of the seniors, but sound can also be very disturbing, and many sounds have so we changed movements that were difficult for many elderly been adjusted based on user feedback. people to perform. Several menu buttons were enlarged and the distance between Eyesight deteriorates with age. We need more light the older them increased. A menu color test was performed to find good we get, and we also see fewer colors. This means that graphics color combinations between button, background, and text. Figure 6. The first and a later version of an “Old farmer” character. With the straw, the players thought he was smoking a pipe. Most (exer)game developers are young, and it is difficult for Discussion the young to realize the limitations of age. This applies to graphics as well as speed and movements. It is therefore highly Prinicipal Findings advisable to apply a user-centered approach when designing for Lately research has been focusing on older adults over 65 years, seniors. It is difficult to recruit the very old, but the authors including how to keep them active. Exergames seems to be a believe that the users should be as close as possible to the promising tool to enable elderly people to be active, but the intended user group both in age and abilities. Senior users are creation of the games can be difficult since no specific often defined as being 55 years and older, but there is often a guidelines exist. As participatory design is central to the creation huge difference between a 55-year-old person and a 95-year-old of serious games, in this paper we propose an adjusted UCD person both in cognitive and physical abilities. In the 3-year protocol tailored to senior users and provide and discuss the period using user-centered design, the average age of our users lessons learned of applying this protocol over almost a 3-year was over 80 years. period. One big challenge was to ensure that the participants understood Taking into consideration the limitation and the cross-validation the questions we posed and gave an accurate reply. For instance, of findings through published literature, the novelty of this paper the nuances were lost on a 5-point Likert scale; we propose lies in the proposal of a UCD protocol and the use of its using only 3 points when this will still give valid results (eg, “I methodologies tailored to seniors’ needs, lessons learned during agree,” “I do not agree,” and “I do not know”). the creation of an exergame applying a UCD approach which Observations are very important and should be emphasized then can be generalized and applied in serious games targeting throughout the protocol, including hints for the observers about seniors, and lessons learned from the application of such a what to look for. This should include errors made during the protocol having seniors as users. This may act as a guide for test but also signs that the participant does not understand or future studies and projects. cannot see details, whether there are games or parts of games http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al they do not want to perform, etc. Filming the different tests and • Gaining trust from the participants and also within the group sessions can be of great help for later analyses. of participants can lead to biased results from participants wanting to please the researchers or developers. Since group discussions can be a challenge and participation • A small steady group could after a while feel that the game was irregular, we developed small questionnaires when we is partly their creation, particularly when they see changes wanted to make sure that we got the opinion of as many as based on their feedback. This can make the users less possible and repeated the sessions in several gatherings to get critical. responses from most participants, sometimes even asking selected persons to arrive before the gatherings started. Further, Comparison With Prior Work in the group discussions we took the time to direct questions at The players often bring their own context into game play and each and every one, coming up closer to the persons to make this should be reflected in exergames for elderly people [19]. sure that they could hear what was being said. The senior population, for instance, often has other preferences than the young when it comes to music and activities that would The very old get exhausted easily, so there should not be too make a game enjoyable. Also, activities from the past that can many questions and certainly not too many that are almost the trigger fond memories could make a good background for game same. We particularly experienced this when going through stories, but as our example with the scythe shows, elderly people color tests. We had 4 sheets, each with 5 menu buttons, and we need to be involved to get the stories and activities correct. wanted to know which ones they could see the best. Toward the end most were exhausted and did not want to continue. Tests When approaching the very old, one needs to be patient and like this should only have small samples and could be performed spend the time that is required to gain trust, but tests and in more than one session. interviews will take longer, and less can be done at a time. Our experiences forming, evaluating, and adjusting the proposed Working with seniors requires trust, which takes time to build. protocol echo the findings of Redish and Chisnell [48] that The group size should not be too big for several reasons: it is recruiting and working with older adults requires special difficult to recruit in this age group, the participants need to communication. gain trust inside the group, and group discussions among the old are challenging. Questionnaires are found difficult to read and fill in. According to our experience, when given a paper questionnaire many will Since many in this user group are more or less computer ask for help to read, explain, and write the replies. If the seniors illiterate, it is also important that they understand that crashes are left alone filling them in, there are often many blanks and and errors are not their fault but the developers’. several replies that indicate that they have not understood the According to Faulkner [43], the number of users in a usability questions. Hayes et al [49] also confirm that seniors often have study probably influences the problem discovery level a study problems filling in quite simple questionnaires on their own, will achieve. He demonstrated that 10 users are able to identify either feeling unable to do so or missing out on questions or a minimum of 82% of the problems with an average problem information given. Questionnaires should therefore be filled in finding of 94.686% while this percentage changes to a minimum by a helper or in structured interviews. This could lead to biased of 90% and an average of 97.050% problems identified by 15 results since they will not be anonymous, but we think that this users. Nielsen [44] advises that 5 participants is optimal for is a smaller problem than not understanding the questions and problem discovering, while Spool and Schroeder [45] support one that can be taken into account when analyzing the results. that problem-discovering relates to the complexity of tasks and Iacono and Marti [50] point out how important it is to create an 5 participants can only identify 35% of the problems in an empathic and trusted relationship between participants and interface. As Macefield [46] demonstrated there is no “one size designers in participatory design with seniors and state that the fits all” solution; however, 5 to 10 participants is a sensible role of the facilitator is crucial. Being in line both with our baseline range for problem discovery while comparative studies experience and the view of Iacono and Marti is that knowledge aiming at statistically significant results should have 10 to 12 is not acquired once and for all by older adults, since they often participants. Furthermore, the length of the study should be forget recent events. taken into consideration. According to Baek et al [47], users participate in a design at the full inclusion level and the Conclusions emancipatory level by cooperating with the researchers and Involving seniors in the entire process can lead to many big and developers or even carry out the design themselves over a long small changes that are essential to make good, safe, and fun period of time. Taking into consideration the average age of the games that the seniors will want to play and thus be motivated participants and the place of the study, the number of users can to exercise more. In this respect, involving senior end users be considered satisfactory and beneficial for this study. when designing exergames for this group is essential. However, Limitations the UCD must be adjusted to suit this user group. There are some limitations in our study. The 3 most important It is important to plan the sessions so as not to exhaust or are confuse the participants, and each session should be short and should not cover too many aspects at once. It is also a good idea • The adjusted protocol was modified during a long period to leave time to perform the same tests or questions/interviews with 1 user group. It should be tried on new groups to be in several sessions in case many participants are absent at the confirmed and further adjusted. http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al first one. Also, questions should be formed with care and movements, the user interface and interaction both with the questionnaires should be short and either filled in using games and the technology, colors, sounds, playability, etc. structured interviews or with a helper at hand. Despite the fact that it might be considered a limitation, another Devoting time to seniors is a key element of the success of a reason for the useful feedback might be that a stable group of UCD so that trust can be gained, communication can be senior users participated in our study. They felt safe both with established, and users’ opinions can be registered. Thus, with each other and with the researchers. The researchers gained some adjustments regarding time and tasks to perform, our their trust by spending much time with them playing, chatting, initial protocol was useful and gave valuable results. and sharing meals and learning the names of all participants. In the development of exergames for seniors applying UCD, It is clear from this research that best practices have been formed all the different game elements should be taken into for UCD of serious games for older adults that look promising consideration during the design of exergames for seniors even for researchers and developers and for facing societal challenges if they seem to be obvious. Those elements include theme, like active and healthy aging as well. Acknowledgments This work is supported by “GameUp: Game-Based Mobility Training and Motivation of Senior Citizens” (www.GameUpproject.eu), a project cofunded under the Ambient Assisted Living Joint Programme (REF. AAL-2011-4-090). All authors were key participants in the project and have participated in developing the protocol and the game and planning and performing the trials. The authors would like to thank the seniors who participated in the biweekly meeting for UCD for over 2-and-a-half years and Vigdis Mellem, the person responsible for planning and arranging the meetings and calling each and every one before each gathering and also arranging with volunteers who would set up the room and serve the meal. These volunteers also deserve our gratitude. Conflicts of Interest None declared. References 1. Kirk A, MacMillan F, Rice M, Carmichael A. An exploratory study examining the appropriateness and potential benefit of the Nintendo Wii as a physical activity tool in adults aged over 55 Years. Interact Comput. 2013. (1) p. 102-114 URL: https://iwc.oxfordjournals.org/content/25/1/102.short[WebCite Cache ID 6nPnFz7YN] 2. Wollersheim D, Merkes M, Shields N, Liamputtong P, Wallis L, Raynolds F, et al. Physical and psycosocial effects of Wii video game use among older women. Int J Emerging Technol Soc 2010;8(2):85-98. 3. Theng Y, Dahlan A, Akmal M, Myint T. An exploratory study on senior citizens’ Perceptions of the Nintendo Wii: the case of Singapore i-CREATe '09. 2009 Presented at: 3rd International Convention on Rehabilitation Engineering & Assistive Technology; 2009; New York. [doi: 10.1145/1592700.1592712] 4. Anderson F, Annett M, Bischof WF. Lean on Wii: physical rehabilitation with virtual reality Wii peripherals. Stud Health Technol Inform 2010;154:229-234. [Medline: 20543303] 5. Konstantinidis ST, Fernandez-Luque L, Brox E, Kummervold PE. Seniors Exergaming 2.0: the role of social and motivational aspects on games for elderly's physical training through Web 2.0 techniques. 2014 Presented at: Proceedings of Medicine 2.0; 2014; Malaga p. 09-10. 6. Brox E, Konstantinidis, Evertsen G, Fernandez-Luque L, Rremartinez A, Oesch P, et al. GameUp: Exergames for mobility: a project to keep elderly active. 2016 Presented at: XIV Mediterranean Conference on Medical and Biological Engineering and Computing; 2016; Paphos, Cyprus p. 1219-1224. 7. Chao Y, Scherer YK, Wu Y, Lucke KT, Montgomery CA. The feasibility of an intervention combining self-efficacy theory and Wii Fit exergames in assisted living residents: A pilot study. Geriatr Nurs 2013;34(5):377-382. [doi: 10.1016/j.gerinurse.2013.05.006] [Medline: 23764366] 8. Williams MA, Soiza RL, Jenkinson AM, Stewart A. Exercising with computers in later life (EXCELL)—pilot and feasibility study of the acceptability of the Nintendo Wii Fit in community-dwelling fallers. BMC Res Notes 2010;3:238 [FREE Full text] [doi: 10.1186/1756-0500-3-238] [Medline: 20831836] 9. Evertsen G, Brox E. Acceptance of a targeted exergame program by elderly. 2015 Presented at: Proceedings from the 13th Scandinavian Conference on Health Informatics; 2015; Tromso, Norway p. 12-15. 10. Brox E, Luque L, Evertsen G, Hernandez JEG. Exergames for elderly: social exergames to persuade seniors to increase physical activity. 2011 Presented at: 5th International Conference on Pervasive Computing Technologies for Healthcare; 2011; Dublin, Ireland p. 546-549. [doi: 10.4108/icst.pervasivehealth.2011.246049] 11. Brox E, Evertsten G, Åsheim-Olsen H, Burkow T, Vognild L. Experience from long-term exergaming with elderly. In: Proceedings of the 18th International Academic Mindtrek Conference. New York: ACM; 2014:216-220. [doi: 10.1145/2676467.2676483] http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al 12. Bird M, Clark B, Millar J, Whetton S, Smith S. Exposure to “Exergames” increases older adults' perception of the usefulness of technology for improving health and physical activity: a pilot study. JMIR Serious Games 2015;3(2):e8 [FREE Full text] [doi: 10.2196/games.4275] [Medline: 26614263] 13. Billis A, Konstantinidis E, Mouzakidis C, Tsolaki M, Pappas C, Bamidis P. A game-like interface for training seniors’ dynamic balance and coordination. IFMBE Proceedings 2010:691-694. 14. Konstantinidis EI, Billis A, Hlauschek W, Panek P, Bamidis PD. Integration of cognitive and physical training in a smart home environment for the elderly people. Stud Health Technol Inform 2010;160(Pt 1):58-62. [Medline: 20841650] 15. Jung Y, Li W, Gladys C, Lee K. Games for a better life: Effects of playing Wii games on the well-being of seniors in a long-term care facility. 2009 Presented at: Proceedings of the Sixth Australasian Conference on Interactive Entertainment; 2009; Sydney, Australia p. 0-5. 16. Rendon AA, Lohman EB, Thorpe D, Johnson EG, Medina E, Bradley B. The effect of virtual reality gaming on dynamic balance in older adults. Age Ageing 2012 Jul;41(4):549-552 [FREE Full text] [doi: 10.1093/ageing/afs053] [Medline: 22672915] 17. Brox E, Evertsen G, Åsheim-Olsen H, Hors-Fraile S, Browne J. Experience with a 3D Kinect exergame for elderly. 2015 Presented at: Proceedings of the 8th International Conference on Health Informatics; 2015; Lisbon, Portugal p. 12-15. [doi: 10.5220/0005165602310238] 18. Konstantinidis ST, Brox E, Kummervold PE, Hallberg J, Evertsen G, Hirche J. Online social exergames for seniors: a pillar of gamification for clinical practice. In: Novák D, Tulu B, Brendryen H, editors. Handbook of Research on Holistic Perspectives in Gamification for Clinical Practice. Hershey, PA: IGI Global; Oct 21, 2015:245-276. [doi: 10.4018/978-1-4666-9522-1.ch012] 19. van der Abeele AA, Van Rompaey RV. Introducing human-centered research to game design: designing game concepts for and with senior citizens. 2006 Presented at: CHI '06 Extended Abstracts on Human Factors in Computing; 2006; Montreal, Canada p. 1469-1474. [doi: 10.1145/1125451.1125721] 20. Gerling K, Schild J, Masuch M. Exergame design for elderly users: the case study of SilverBalance. 2010 Presented at: Proceedings of the 7th International Conference on Advances in Computer Entertainment Technology; 2010; Taipei, Taiwan p. 66-69. 21. Ergonomics of human-system interaction—Part 210: Human-centred design for interactive systems. URL: https://www. iso.org/obp/ui/#iso:std:iso:9241:-210:ed-1:v1:en [accessed 2016-12-16] 22. Karat J, Karat CM. The evolution of user-centered focus in the human-computer interaction field. IBM Syst J 2003;42(4):532-541. [doi: 10.1147/sj.424.0532] 23. Sebe N. Human-centered computing. In: Handbook of Ambient Intelligence and Smart Environments. New York: Springer; 2010:349-370. [doi: 10.1007/978-0-387-93808-0_13] 24. Proffitt R, Lange B. User centered design and development of a game for exercise in older adults. Int J Technol Knowl Soc 2012;8(5):112. 25. van der Weegen S, Verwey R, Spreeuwenberg M, Tange H, van der Weijden T, de Witte WL. The development of a mobile monitoring and feedback tool to stimulate physical activity of people with a chronic disease in primary care: a user-centered design. JMIR Mhealth Uhealth 2013;1(2):e8 [FREE Full text] [doi: 10.2196/mhealth.2526] [Medline: 25099556] 26. Vredenburg K, Mao J, Smith P, Carey T. A survey of user-centered design practice. 2002 Presented at: Proceedings of the SIGCHI Conference on Human Factors in Computing Systems; 2002; Minneapolis, MN p. 3460-3478. [doi: 10.1145/503376.503460] 27. Gregor P, Newell A, Zajicek M. Designing for dynamic diversity: interfaces for older people. 2002 Presented at: Proceedings of the 5th international ACM conference on Assistive technologies; 2002; Edinburgh, UK p. 151-156. [doi: 10.1145/638249.638277] 28. Thimbleby H. Understanding user centred design (UCD) for people with special needs. In: Miesenberger K, editor. Computers Helping People with Special Needs. Berlin: Springer; 2008. 29. Zajicek M. Successful and available: interface design exemplars for older users. Interact Comput 2004:411-430. [doi: 10.1016/j.intcom.2004.04.003] 30. Billis A, Konstantinidis E, Ladas A, Tsolaki M, Pappas C, Bamidis P. Evaluating affective usability experiences of an exergaming platform for seniors. Biomed Eng 2011:1-4. [doi: 10.1109/IWBE.2011.6079048] 31. Dickinson A, Arnott J, Prior S. Methods for human-computer interaction research with older people. Behav Inf Technol 2007;26(4):343-352. [doi: 10.1080/01449290601176948] 32. Holt B. Creating senior-friendly Web sites. Issue Brief Cent Medicare Educ 2000;1(4):1-8. [Medline: 11817407] 33. AgeLight. Interface Design Guidelines for Users of all Ages. 2001. URL: http://www.agelight.com/webdocs/designguide. pdf [accessed 2016-02-15] [WebCite Cache ID 6fJZssXUM] 34. Kurniawan S, Zaphiris P. Research-derived Web design guidelines for older people. 2005 Presented at: Proceedings of 7th international ACM SIGACCESS Conference on Computers and Accessibility; 2005; Baltimore, MD p. 129-135. [doi: 10.1145/1090785.1090810] 35. National Institute on Aging, National Library of Medicine. Making your Web site senior friendly: a checklist. 2002. URL: https://www.nlm.nih.gov/pubs/checklist.pdf [accessed 2016-02-15] [WebCite Cache ID 6fJaI60tL] http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al 36. Bamidis PD, Gabarron E, Hors-Fraile S, Konstantinidis E, Konstantinidis S, Rivera O. Gamification and behavioral change: techniques for health social media. In: Syed-Abdul S, Gabarron E, Lau A, editors. Participatory Health Through Social Media. London: Elsevier; Jun 17, 2016:112-135. 37. Chrisnell D, Redish J. Designing web sites for older adults: expert review of usability for older adults at 50 Web sites. AARP. 2005. URL: http://www.redish.net/images/stories/PDF/AARP-50Sites.pdf [accessed 2016-12-16] [WebCite Cache ID 6mo2iujhA] 38. Kurniawan S, King A, Evans D, Blenkhorn P. Personalising Web page presentation for older people. Interact Comput 2006 May;18(3):457-477. [doi: 10.1016/j.intcom.2005.11.006] 39. Fidgeon T. Usability for Older Web Users. WebCredible. 2006. URL: http://www.webcredible.com/blog/ usability-older-web-users/ [accessed 2016-02-15] [WebCite Cache ID 6fJbSkwzL] 40. Arch A, Abou-Zahra S. Developing websites for older people: how web content accessibility guidelines (WCAG) 2.0 applies. Web Accessibility Initiative. 2010. URL: https://www.w3.org/WAI/older-users/developing.html [accessed 2016-02-15] [WebCite Cache ID 6fJbgt5SI] 41. Awad M, Ferguson S, Craig C. Designing games for older adults: an affordance-based approach. 2014 Presented at: IEEE 3nd International Conference on Serious Games and Applications for Health (SeGAH); 2014; Rio de Janeiro, Brazil URL: http://doi.org/10.1109/SeGAH.2014.7067103 [doi: 10.1109/SeGAH.2014.7067103] 42. Hors Fraile S, Browne J, Brox E, Evertsen G. Suitability analysis of commercial open-source driven motion sensor devices applied to exergames for the elderly. Ambient Assisted Living Forum Eindhoven 2012. 43. Faulkner L. Beyond the five-user assumption: benefits of increased sample sizes in usability testing. Behav Res Methods Instrum Comput 2003 Aug;35(3):379-383. [Medline: 14587545] 44. Nielsen Norman Group. Why You Only Need to Test With 5 Users. 2000. URL: https://www.nngroup.com/articles/ why-you-only-need-to-test-with-5-users/ [accessed 2016-11-29] [WebCite Cache ID 6mOEaiOUa] 45. Spool J, Schroeder W. Testing web sites: five users is nowhere near enough. 2001 Presented at: CHI '01 Extended Abstracts on Human Factors in Computing Systems; 2001; Seattle. [doi: 10.1145/634067.634236] 46. Macefield R. How to specify the participant group size for usability studies: a practitioner's guide. J Usability Studies 2009;5(1):34-45 [FREE Full text] 47. Baek EO, Cagiltay K, Boling E, Frick T. User-centered design and development. In: Spector JM, Merrill MD, van Merrienboer JJ, Driscoll MF, editors. Handbook of Research on Educational Communications and Technology, Third edition. London: Routledge; 2008:659-570. 48. Redish J, Chisnell D. Designing web sites for older adults: a review of recent research. AARP. 2004. URL: http://www. redish.net/images/stories/PDF/AARP-LitReview2004.pdf [accessed 2016-02-15] [WebCite Cache ID 6fJcYH312] 49. Hayes V, Morris J, Wolfe C, Morgan M. The SF-36 health survey questionnaire: is it suitable for use with older adults? Age Ageing 1995 Mar;24(2):120-125. [Medline: 7793333] 50. Iacono I, Marti P. Engaging older people with participatory design. 2014 Presented at: Proceedings of the 8th Nordic Conference on Human-Computer Interaction: Fun, Fast, Foundational; 2014; Helsinki, Finland p. 859-864. [doi: 10.1145/2639189.2670180] Abbreviations UCD: user-centered design Edited by G Eysenbach; submitted 22.06.16; peer-reviewed by ML Bird, M Immonen, C Giraud-Carrier; comments to author 25.07.16; revised version received 30.11.16; accepted 30.11.16; published 11.01.17 Please cite as: Brox E, Konstantinidis ST, Evertsen G User-Centered Design of Serious Games for Older Adults Following 3 Years of Experience With Exergames for Seniors: A Study Design JMIR Serious Games 2017;5(1):e2 URL: http://games.jmir.org/2017/1/e2/ doi: 10.2196/games.6254 PMID: 28077348 ©Ellen Brox, Stathis Th Konstantinidis, Gunn Evertsen. Originally published in JMIR Serious Games (http://games.jmir.org), 11.01.2017. 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, http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al 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/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 14 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

User-Centered Design of Serious Games for Older Adults Following 3 Years of Experience With Exergames for Seniors: A Study Design

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Background: Seniors need sufficient balance and strength to manage in daily life, and sufficient physical activity is required to achieve and maintain these abilities. This can be a challenge, but fun and motivational exergames can be of help. However, most commercial games are not suited for this age group for several reasons. Many usability studies and user-centered design (UCD) protocols have been developed and applied, but to the best of our knowledge none of them are focusing on seniors’ use of games for physical activity. In GameUp, a European cofunded project, some prototype Kinect exergames to enhance the mobility of seniors were developed in a user-centered approach. Objective: In this paper we aim to record lessons learned in 3 years of experience with exergames for seniors, considering both the needs of older adults regarding user-centered development of exergames and participation in UCD. We also provide a UCD protocol for exergames tailored to senior needs. Methods: An initial UCD protocol was formed based on literature of previous research outcomes. Senior users participated in UCD following the initial protocol. The users formed a steady group that met every second week for 3 years to play exergames and participate in the UCD during the 4 phases of the protocol. Several methods were applied in the 4 different phases of the UCD protocol; the most important methods were structured and semistructured interviews, observations, and group discussions. Results: A total of 16 seniors with an average age above 80 years participated for 3 years in UCD in order to develop the GameUp exergames. As a result of the lessons learned by applying the different methodologies of the UCD protocol, we propose an adjusted UCD protocol providing explanations on how it should be applied for seniors as users. Questionnaires should be turned into semistructured and structured interviews while user consultation sessions should be repeated with the same theme to ensure that the UCD methods produce a valid outcome. By first following the initial and gradually the adjusted UCD protocol, the project resulted in exergame functionalities and interface features for seniors. Conclusions: The main lessons learned during 3 years of experience with exergames for seniors applying UCD are that devoting time to seniors is a key element of success so that trust can be gained, communication can be established, and users’ opinions can be recorded. All different game elements should be taken into consideration during the design of exergames for seniors even if they seem obvious. Despite the limitations of this study, one might argue that it provides a best practice guide to the development of serious games for physical activity targeting seniors. (JMIR Serious Games 2017;5(1):e2) doi: 10.2196/games.6254 http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al KEYWORDS user studies; usability testing; gestural input; user-centred design; accessibility; consumer health; exergames; participatory design; lessons learned Why a Unique Design for Seniors? Introduction It has been established in several studies that seniors enjoy Overview playing exergames and they believe exergames can assist in maintaining physical activity [7-12]. Despite the fact that Physical activity is important at all ages, and seniors particularly balance and rehabilitation of seniors can be maintained and need sufficient strength, balance, and flexibility to manage in improved through exergames [2,3,7,8,13-16], not many are everyday life. This is particularly true for those ages 65 years designed for this age group [11,17,18]. Game designers use and older. their creativity for game ideas, but since designers normally are Exergames can be a method to motivate seniors to exercise and young, they do not often consider the needs of seniors [19]. The hence get more physical activity with sufficient physical exertion game stories might therefore not be of interest for the senior [1]. Most commercial games are, however, not suited for this population. group for several reasons including speed, amount of A trial using Nintendo Wii exergames for seniors indicated that information, required movements, etc [2-4]. age-related impairments influence the use of video games among GameUp, a project cofunded by the European Union, Spain, frail elderly, so this should also be considered in the design Norway, and Switzerland [5,6] aimed at creating useful and process [20]. We have indeed observed that there are many motivational exergames for seniors, was undertaken with a obstacles for seniors playing commercial exergames, and this user-centered approach during the design and development has been confirmed in other studies [4,7]. Also, existing games process to meet the users’ limitations and requirements. for the young are not developed to meet the physical exercise needs of elderly people. Based on these findings we can Despite the fact that many usability studies and user-centered conclude that good and safe exergames should be developed design (UCD) protocols have been developed, to the best of our particularly for seniors, both regarding movements and narrative. knowledge none of them have focused on seniors’ use of games for physical activity (ie, exergames). Furthermore, there is What Is User-Centered Design? limited information regarding the design and functionality of The International Organization for Standardization uses the serious games for seniors and more specifically for exergames. term “human-centered design” and defines it to be an “approach An initial UCD protocol was created based on literature and to systems design and development that aims to make interactive previous research outcomes in order to develop the GameUp systems more usable by focusing on the use of the system and project exergames. During the project, we followed that protocol applying human factors/ergonomics and usability knowledge and adjusted it based on 3 years’ experience in order to meet and techniques” [21]. The same standard also states that this the needs of both the project and the users. In this paper we term in practice is used synonymously with UCD. According report the lessons learned for the different phases of the protocol to Karat and Karat [22], “UCD defines iterative processes whose and the adjustments that our initial protocol needed in order to goal is the development of usable systems.” According to Sebe be applicable to older adults and we highlight the most important [23], “user-centered design (UCD) is a process (not restricted UCD influences and recommendations on the GameUp to interfaces or technologies) in which the needs, wants, and exergames. limitations of end users of a product, service, or process are The remainder of the paper is structured as follows. Initially, given extensive attention at each stage of the design process. we set the scene by pinpointing the need for unique design for UCD can be characterized as a multistage problem-solving seniors, exploring the UCD, and identifying the need for a process that not only requires designers to analyze and foresee specific UCD for seniors. In the Methods section we describe how users are likely to use a product but also to test the validity all the necessary elements of lessons learned, namely the UCD of their assumptions with regard to user behavior in real world protocol which served as the base of our exergames tests with actual users.” implementation, the recruitment criteria for the seniors, the Since UCD can be considered a multistage process, one will GameUp exergames, and the considered ethical aspects and normally use different methods in different stages. Both risks. Next, the Results section describes the lessons learned qualitative and quantitative methods were used by Proffitt and from a 3-point view: (1) the lessons learned during the different Lange [24] while implementing a UCD. They used focus groups protocol phases, (2) changes and tips for our initial protocol on as well as an iterative user-testing process while testing changes the different methodologies of the UCD protocol, and (3) the to a prototype. One study [25] used a 3-stage qualitative UCD lessons learned from the important changes of our developed approach in the requirement phase including literature search exergames. The Results section points out the initial protocol’s and focus groups. The actual use of UCD in the industry was weaknesses against the existing literature including the studied by Vredenburg et al [26] wherein 13 methods were limitations of our approach. Finally, the Conclusions section identified, among them field studies, user requirements analyses, sums up the lessons learned and emphasizes the key issues on iterative design, usability evaluation, task analyses, focus groups, applying UCD with seniors. user interviews, participatory design, and prototypes. Several of these methods have been used in our initial protocol. http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al be flexible on timing to maintain participation in a long-term Need for a Specific User-Centered Design for Seniors study. Gregor et al [27] further conclude that UCD principles need to be employed for seniors. Seniors are different from the young; Existing research on Web design for elderly people shows the “functionality, needs, and wants differ from the young even importance of designing and implementing games and though they consider themselves as fit, but many often have applications uniquely targeting elderly people. We have several physical problems with a general reduction in identified some initiatives and research aimed at providing functionalities” [27]. The authors further refer to the difficulty guidelines for the design and accessibility of websites for elderly both of recruiting representatives from this group and of people [32-40]. AgeLight [33] points out the importance of communicating with them. player-centered design, meaning that the seniors should be brought in early in the design process. An affordance-based When users have special needs like the senior users do, the costs approach to designing a game was followed by Awad et al [41] of applying UCD increases as the users have more diverse emphasizing “the type of action the user can perform but also requirements [28]. Zaijcek [29] concluded that it is difficult to when (response times) and how it can be performed (range of arrange traditional focus groups for seniors, which is a common motion).” In this study the authors followed an iterative testing method in UCD. Focus groups should be adapted for older process starting with an early prototype. people, and their organization requires considerable interpersonal skills. They conclude that interface design for Despite the fact that some studies followed a UCD, to the best seniors is more complex than for other groups. of our knowledge none of the studies coded and formed a UCD protocol for exergames targeting seniors. In addition, there are According to Zajicek, “adults as they get older experience a few studies that recorded the needs of the older adults either for wide range of age-related impairments including loss of vision, the creation of exergames or as being part of a UCD. hearing, memory and mobility, the combined effects of which contribute to loss of confidence and difficulties in orientation Methods and absorption of information” [29]. With age, eyesight and hearing deteriorate and seniors require more time to think and Recruitment get an overview [10,30]. Also motoric skills deteriorate with One of the partners in the project was a senior center, and the age, and many seniors have health conditions limiting their participants in the UCD were recruited from its members. In abilities. order to ensure that participants would be available throughout Dickinson et al [31] made a list of guidelines for maximizing the duration of the GameUp project, a regular group was formed the research outcomes of working with older adults. The test that met every second week to play exergames and share a meal. case was to learn to use email, but some of the recommendations Researchers would participate often but not at all gatherings. are also valid for exergame development. One is to put great All testing, interviews, etc, were performed at these gatherings. care into making sure information and instructions are To ensure that the participants were in the target group for the understood; another is that one has to be flexible when it comes GameUp project and also competent to sign an informed to timing during trials. They also point out the difficulties of consent, inclusion and exclusion criteria were defined (Textbox recruitment and the importance of being able to reschedule and 1). Textbox 1. Eligibility criteria. Inclusion criteria: Aged 65 years or older Risk of falling or history of falling Recent illness or surgery Impaired strength or balance Exclusion criteria: Cognitive impairment, defined as a Mini Mental State Examination score below 25 Other disease, illness, or limiting condition that would make inclusion and beneficial use of the system difficult, such as complete blindness, deafness, or severe disabilities on the aforementioned literature and on indications through Definition of a High-Level Protocol for User-Centered previous research engaging seniors and exergames on a much Design of Exergames for Seniors smaller scale [10]. This protocol was then tested during the A high-level protocol for UCD of exergames for seniors was GameUp project on a group of seniors over a 3-year period. A developed by the authors as depicted in Figure 1. This was based description of the design protocol and how it was used follows. http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al Figure 1. The 4 phases and the methods used in each of the phases. exergame with smaller new user groups can also give valuable Phases of Development input. The methods for user involvement in this phase are Requirement Gathering and Analyses • Structured and semistructured interviews The main objective of this phase was to gather requirements • Observations for an initial design by collecting basic requirements and needs • Questionnaires of the end users for the chosen group as well as requirements • Prototype tests with new participants for the games to be developed by defining useful exercises. The The Games methods for the user involvement in this phase included Microsoft Kinect was chosen for development based on usability • Literature study studies [42]. The movements included exercises for balance, • Questionnaire with background information flexibility, and strength, all important for mastering daily • Observations while end users play commercial exergames activities. • Group discussions A total of 7 minigames were developed. The 3 balance games • Existing knowledge in the project group are based on the same concept but with different graphics, and Design thus they appear as different games. In these games, one is In this phase, the initial design of the games become more supposed to catch things that fall from above. The falling items detailed using an iterative approach. The users should have a (apples, stars, and chickens) are of 2 different colors, and they real opportunity to influence the outcome of the design by giving need to be put in the correct basket. In addition, 4 different feedback. This phase includes the following methods for user minigames for leg strength and flexibility were developed. Since involvement: there was a big difference in abilities in the user group, the games have several difficulty levels. • Observations • Semistructured interviews Ethical Aspects and Risks • Group discussions Ethical aspects and risks must be identified, including an exit strategy if the participants are enjoying and even getting Implementation dependent on the GameUp project results. In our case there The implementation phase follows an iterative approach based were no direct medical interventions, but many exercises are on feedback and user reactions. Detailed descriptions of the performed standing, and there could be a risk of falling. Some design may need to be adjusted merging different parts of the can play alone; for others there must either be a person or chair game. During the implementation phase, methods for user for support. Some will even play seated or use a walking frame. involvement are A Berg Balance Scale was performed for all the users before • Observations the start of the UCD to define the appropriate level of exercises. • Semistructured and structured interviews To avoid any further risk, all the participants were informed • Group discussions about proper use of the system. Evaluation The participants have no economic interest or obligations related In the evaluation phase, the emphasis is on the final prototypes. to the GameUp project, and participants hold the right to exit The most common approach is to run pilot tests, but testing the http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al the project at any time without having to provide a reason for Design this and without consequences. Videotaping proved to be useful in order to analyze the reactions of the users to different tests. Furthermore, we identified that Ethical approval for this study was granted by the Data all the different elements should be taken into consideration Protection Official for Research in Norway. during the design of exergames for elderly, including theme, movements, user interface and interaction both with the games Results and the technology, colors, sounds, playability, etc. As explained above, we developed Kinect-based exercises. During the design Study Participants phase, we aimed both to learn how the users reacted to this type Approximately 7 to 10 seniors would be present at each of interface and which of the physiotherapist-defined movements gathering, and they were retirees in the age range of 66 to 95 would be suited for Kinect games. All the different elements years. In total 16 persons participated. were presented progressively to the users. Initially, the first All participants signed an informed consent and were aware of design was presented to the users by presenting graphics on the fact that they were participating in a research project in paper and then the interaction with the system was introduced which a UCD method would be followed to implement the by presenting the physical movements required. Later, design GameUp exergames. During the 3 years, several members left elements like sound and graphics were introduced. the group for various reasons, and new ones were recruited. Implementation Reasons for discontinuation were varied: 1 moved to a care Detailed descriptions of the design were adjusted during this home far away, a couple got too sick to continue, 1 died, and 1 phase since merging different elements of the design required had a steep cognitive decline and could no longer participate. additional user input. Different tests of the exergames were The average age was over 80 years but because of the time span performed using different methods depending on what was and replacements, this was not constant. The first established appropriate: (1) test of early prototypes, (2) iterative tests with group consisted of 9 participants, 1 man and 8 women aged 71 changes according to outcomes from previous tests, (3) tests of to 95 years with an average age of 83 years. Toward the end of user interface elements (coming together), and (4) test of the the GameUp project at the completion of the UCD protocol, playability of the game with focus on game story and game there were 10 participants, 2 men and 8 women in the age range theme. of 66 to 90 years with an average age of 81.7 years. Evaluation Lessons Learned Using User-Centered Design With As part of this phase we tested the final prototype with our Seniors group. We observed that the group that participated throughout the other 3 phases of the UCD protocol provided feedback Lessons Learned During the User-Centered Design during this phase as well, with a few alterations as described in Protocol Phases the Study Participants subsection. Requirement Gathering and Analyses Lessons Learned Applying the User-Centered Design During this phase, a multidisciplinary team should be involved Protocol Methodologies from the beginning. Important inputs for our exergames design Our initial UCD protocol was used throughout the project in a were that physiotherapists defined suitable exercises to help the UCD methodology although it was slightly adjusted to enable mobility of seniors, developers studied the possibilities of the us to reach our goal. The lessons learned could be summed up different tracking movement technologies such as Wii and as a series of tips and adjustments for the creation of serious Kinect, and game designers considered game elements, etc. games for seniors and are summarized in Figure 2. http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al Figure 2. Adjustment to initial protocol for user-centered design (UCD) design having seniors as users. planned, resulting in minimizing both the number of questions Questionnaires in Interviews and the number of answering options and spending more time Questionnaires were part of our initial UCD protocol during on getting useful answers. the “Requirement Gathering and Analyses” and “Evaluation” Semistructured and Structured Interviews phases. In order to apply those to our user group, we realized that we had to adjust them by reducing the questions for each In the semistructured interviews, we had some open questions session because the users found it hard to concentrate for a long and discussions in addition to the structured interviews where period and they got exhausted very quickly. If there were many we wanted to learn about users’ opinions on specific topics. At questions, we would observe very visible signs of fatigue and the beginning of the application of the UCD protocol, we more loss of concentration. or less only got replies to direct questions, which made us think that only structured interviews should be used, but toward the To this extent, we completed all questionnaires in the form of end of the application of the UCD protocol many would give structured or semistructured interviews since many of the their own suggestions and that allowed us to constructively participants had problems both reading and writing and many include semistructured interviews. also had problems understanding some of the questions despite the fact that they met the inclusion and exclusion criteria. Some Observations of the participants also tended to unintentionally skip questions, Researchers often observed the seniors as they played both so the questionnaires have to be short and very clear if used. commercial games and the GameUp project–developed games. In the observations, we could see how they mastered both the When a 5-point Likert scale was used, the facilitators of the game technology and the movements but also how much they session turned the questionnaires into structured interviews as did not perceive. This was particularly the case in many of the explained above. Furthermore, additional time had to be spent commercial games. Based on observations, we also defined on getting a proper reply. For example, a common answer in questions for group discussions and structured interviews about this case was “That is fine” in order to avoid a thorough reply. the project games. For instance, we had the feeling that most Also the way many responded on color tests gave the impression could only see exactly what they were doing in the game even that they wanted to tell there was nothing wrong with their if the graphics were very simple and clear. We therefore asked eyesight instead of telling what they could see the best. Finally whether they could see information on the top of the screen a different approach was taken on the questioning than first http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al about the points earned while they were playing. In fact, nobody and frequently we had to repeat the responses so that all could could see it even though they had been playing the same game hear what had been said. several times as well as watching others play. We also observed Another important lesson learned is that replies would often repeated errors and could adjust the game accordingly. come gradually playing the same game version in several We used observations to see the users’ reactions to the design sessions. Repetitions were also important to get the response elements as well as to detect errors and misunderstandings. from as many as possible, since there were always some who Observations also made us change graphics or parameters: the were not present at specific gatherings. speed of the games or the placement of menu buttons, for As an example of the outcome of group discussion, one theme example. We also made sure that it was possible to get that was successfully discussed was the perceived contents or information before or after gameplay instead of during the game. game story. In one minigame the players perform knee bends, which results in water coming from a pump and into a bucket Group Discussions (Figure 4). Occasionally a cow would pass by and bellow, so The setting of the group discussion was as follows: the entire many players wanted the water to run into a trough for the cows group would sit in a semicircle in front of the screen with the instead of a bucket. Another example is a flexibility game where person playing in front, and they would take turns playing the players use a scythe. Most of the players had used scythes (Figure 3). In between playing or before and after we would in their youth and were a bit frustrated that it was cutting in the initiate small group discussions while all were seated by wrong direction. In the game, the corn was cut when the scythe triggering a discussion through questions about the game, was on the way back, but in reality you have to cut on the first particularly if we had introduced something new. We found the move and then swing the scythe back. setting appropriate since the users didn’t have to change places between observing or playing the game and discussing. Issues Many changes occurred to the developed exergames through we brought up during the group discussions included hearing the 3 years of the GameUp project. We briefly describe the ones issues of the users. Hearing is a problem for many elderly that can be generalized to other games in Figure 5. people; we experienced that we often had to repeat questions Figure 3. Seated in front of the screen ready to play. http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al Figure 4. Bending knees to get water. Figure 5. Most important exergames elements and functionality as resulted from 3 years of experience with exergames for seniors. http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al need to be clear and bright, and users’ feedback helped us Lessons Learned From Exergames Targeting change graphics. Also small details were lost. For instance, the Seniors—Important Changes straw and apple in Figure 6 was perceived as a pipe, so the straw Among the most important elements of the games were speed, was removed. This also means that fonts must be big and clear, both of some movements and of the game progress. In our and there should be as little text as possible, preferably exergames, we needed to reduce the speed of both and in accompanied by oral feedback. Oral information is important, addition adapt the game to the physical ability of the seniors, but sound can also be very disturbing, and many sounds have so we changed movements that were difficult for many elderly been adjusted based on user feedback. people to perform. Several menu buttons were enlarged and the distance between Eyesight deteriorates with age. We need more light the older them increased. A menu color test was performed to find good we get, and we also see fewer colors. This means that graphics color combinations between button, background, and text. Figure 6. The first and a later version of an “Old farmer” character. With the straw, the players thought he was smoking a pipe. Most (exer)game developers are young, and it is difficult for Discussion the young to realize the limitations of age. This applies to graphics as well as speed and movements. It is therefore highly Prinicipal Findings advisable to apply a user-centered approach when designing for Lately research has been focusing on older adults over 65 years, seniors. It is difficult to recruit the very old, but the authors including how to keep them active. Exergames seems to be a believe that the users should be as close as possible to the promising tool to enable elderly people to be active, but the intended user group both in age and abilities. Senior users are creation of the games can be difficult since no specific often defined as being 55 years and older, but there is often a guidelines exist. As participatory design is central to the creation huge difference between a 55-year-old person and a 95-year-old of serious games, in this paper we propose an adjusted UCD person both in cognitive and physical abilities. In the 3-year protocol tailored to senior users and provide and discuss the period using user-centered design, the average age of our users lessons learned of applying this protocol over almost a 3-year was over 80 years. period. One big challenge was to ensure that the participants understood Taking into consideration the limitation and the cross-validation the questions we posed and gave an accurate reply. For instance, of findings through published literature, the novelty of this paper the nuances were lost on a 5-point Likert scale; we propose lies in the proposal of a UCD protocol and the use of its using only 3 points when this will still give valid results (eg, “I methodologies tailored to seniors’ needs, lessons learned during agree,” “I do not agree,” and “I do not know”). the creation of an exergame applying a UCD approach which Observations are very important and should be emphasized then can be generalized and applied in serious games targeting throughout the protocol, including hints for the observers about seniors, and lessons learned from the application of such a what to look for. This should include errors made during the protocol having seniors as users. This may act as a guide for test but also signs that the participant does not understand or future studies and projects. cannot see details, whether there are games or parts of games http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al they do not want to perform, etc. Filming the different tests and • Gaining trust from the participants and also within the group sessions can be of great help for later analyses. of participants can lead to biased results from participants wanting to please the researchers or developers. Since group discussions can be a challenge and participation • A small steady group could after a while feel that the game was irregular, we developed small questionnaires when we is partly their creation, particularly when they see changes wanted to make sure that we got the opinion of as many as based on their feedback. This can make the users less possible and repeated the sessions in several gatherings to get critical. responses from most participants, sometimes even asking selected persons to arrive before the gatherings started. Further, Comparison With Prior Work in the group discussions we took the time to direct questions at The players often bring their own context into game play and each and every one, coming up closer to the persons to make this should be reflected in exergames for elderly people [19]. sure that they could hear what was being said. The senior population, for instance, often has other preferences than the young when it comes to music and activities that would The very old get exhausted easily, so there should not be too make a game enjoyable. Also, activities from the past that can many questions and certainly not too many that are almost the trigger fond memories could make a good background for game same. We particularly experienced this when going through stories, but as our example with the scythe shows, elderly people color tests. We had 4 sheets, each with 5 menu buttons, and we need to be involved to get the stories and activities correct. wanted to know which ones they could see the best. Toward the end most were exhausted and did not want to continue. Tests When approaching the very old, one needs to be patient and like this should only have small samples and could be performed spend the time that is required to gain trust, but tests and in more than one session. interviews will take longer, and less can be done at a time. Our experiences forming, evaluating, and adjusting the proposed Working with seniors requires trust, which takes time to build. protocol echo the findings of Redish and Chisnell [48] that The group size should not be too big for several reasons: it is recruiting and working with older adults requires special difficult to recruit in this age group, the participants need to communication. gain trust inside the group, and group discussions among the old are challenging. Questionnaires are found difficult to read and fill in. According to our experience, when given a paper questionnaire many will Since many in this user group are more or less computer ask for help to read, explain, and write the replies. If the seniors illiterate, it is also important that they understand that crashes are left alone filling them in, there are often many blanks and and errors are not their fault but the developers’. several replies that indicate that they have not understood the According to Faulkner [43], the number of users in a usability questions. Hayes et al [49] also confirm that seniors often have study probably influences the problem discovery level a study problems filling in quite simple questionnaires on their own, will achieve. He demonstrated that 10 users are able to identify either feeling unable to do so or missing out on questions or a minimum of 82% of the problems with an average problem information given. Questionnaires should therefore be filled in finding of 94.686% while this percentage changes to a minimum by a helper or in structured interviews. This could lead to biased of 90% and an average of 97.050% problems identified by 15 results since they will not be anonymous, but we think that this users. Nielsen [44] advises that 5 participants is optimal for is a smaller problem than not understanding the questions and problem discovering, while Spool and Schroeder [45] support one that can be taken into account when analyzing the results. that problem-discovering relates to the complexity of tasks and Iacono and Marti [50] point out how important it is to create an 5 participants can only identify 35% of the problems in an empathic and trusted relationship between participants and interface. As Macefield [46] demonstrated there is no “one size designers in participatory design with seniors and state that the fits all” solution; however, 5 to 10 participants is a sensible role of the facilitator is crucial. Being in line both with our baseline range for problem discovery while comparative studies experience and the view of Iacono and Marti is that knowledge aiming at statistically significant results should have 10 to 12 is not acquired once and for all by older adults, since they often participants. Furthermore, the length of the study should be forget recent events. taken into consideration. According to Baek et al [47], users participate in a design at the full inclusion level and the Conclusions emancipatory level by cooperating with the researchers and Involving seniors in the entire process can lead to many big and developers or even carry out the design themselves over a long small changes that are essential to make good, safe, and fun period of time. Taking into consideration the average age of the games that the seniors will want to play and thus be motivated participants and the place of the study, the number of users can to exercise more. In this respect, involving senior end users be considered satisfactory and beneficial for this study. when designing exergames for this group is essential. However, Limitations the UCD must be adjusted to suit this user group. There are some limitations in our study. The 3 most important It is important to plan the sessions so as not to exhaust or are confuse the participants, and each session should be short and should not cover too many aspects at once. It is also a good idea • The adjusted protocol was modified during a long period to leave time to perform the same tests or questions/interviews with 1 user group. It should be tried on new groups to be in several sessions in case many participants are absent at the confirmed and further adjusted. http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al first one. Also, questions should be formed with care and movements, the user interface and interaction both with the questionnaires should be short and either filled in using games and the technology, colors, sounds, playability, etc. structured interviews or with a helper at hand. Despite the fact that it might be considered a limitation, another Devoting time to seniors is a key element of the success of a reason for the useful feedback might be that a stable group of UCD so that trust can be gained, communication can be senior users participated in our study. They felt safe both with established, and users’ opinions can be registered. Thus, with each other and with the researchers. The researchers gained some adjustments regarding time and tasks to perform, our their trust by spending much time with them playing, chatting, initial protocol was useful and gave valuable results. and sharing meals and learning the names of all participants. In the development of exergames for seniors applying UCD, It is clear from this research that best practices have been formed all the different game elements should be taken into for UCD of serious games for older adults that look promising consideration during the design of exergames for seniors even for researchers and developers and for facing societal challenges if they seem to be obvious. Those elements include theme, like active and healthy aging as well. Acknowledgments This work is supported by “GameUp: Game-Based Mobility Training and Motivation of Senior Citizens” (www.GameUpproject.eu), a project cofunded under the Ambient Assisted Living Joint Programme (REF. AAL-2011-4-090). All authors were key participants in the project and have participated in developing the protocol and the game and planning and performing the trials. The authors would like to thank the seniors who participated in the biweekly meeting for UCD for over 2-and-a-half years and Vigdis Mellem, the person responsible for planning and arranging the meetings and calling each and every one before each gathering and also arranging with volunteers who would set up the room and serve the meal. These volunteers also deserve our gratitude. Conflicts of Interest None declared. References 1. Kirk A, MacMillan F, Rice M, Carmichael A. An exploratory study examining the appropriateness and potential benefit of the Nintendo Wii as a physical activity tool in adults aged over 55 Years. Interact Comput. 2013. (1) p. 102-114 URL: https://iwc.oxfordjournals.org/content/25/1/102.short[WebCite Cache ID 6nPnFz7YN] 2. Wollersheim D, Merkes M, Shields N, Liamputtong P, Wallis L, Raynolds F, et al. Physical and psycosocial effects of Wii video game use among older women. Int J Emerging Technol Soc 2010;8(2):85-98. 3. Theng Y, Dahlan A, Akmal M, Myint T. An exploratory study on senior citizens’ Perceptions of the Nintendo Wii: the case of Singapore i-CREATe '09. 2009 Presented at: 3rd International Convention on Rehabilitation Engineering & Assistive Technology; 2009; New York. [doi: 10.1145/1592700.1592712] 4. Anderson F, Annett M, Bischof WF. Lean on Wii: physical rehabilitation with virtual reality Wii peripherals. Stud Health Technol Inform 2010;154:229-234. [Medline: 20543303] 5. Konstantinidis ST, Fernandez-Luque L, Brox E, Kummervold PE. Seniors Exergaming 2.0: the role of social and motivational aspects on games for elderly's physical training through Web 2.0 techniques. 2014 Presented at: Proceedings of Medicine 2.0; 2014; Malaga p. 09-10. 6. Brox E, Konstantinidis, Evertsen G, Fernandez-Luque L, Rremartinez A, Oesch P, et al. GameUp: Exergames for mobility: a project to keep elderly active. 2016 Presented at: XIV Mediterranean Conference on Medical and Biological Engineering and Computing; 2016; Paphos, Cyprus p. 1219-1224. 7. Chao Y, Scherer YK, Wu Y, Lucke KT, Montgomery CA. The feasibility of an intervention combining self-efficacy theory and Wii Fit exergames in assisted living residents: A pilot study. Geriatr Nurs 2013;34(5):377-382. [doi: 10.1016/j.gerinurse.2013.05.006] [Medline: 23764366] 8. Williams MA, Soiza RL, Jenkinson AM, Stewart A. Exercising with computers in later life (EXCELL)—pilot and feasibility study of the acceptability of the Nintendo Wii Fit in community-dwelling fallers. BMC Res Notes 2010;3:238 [FREE Full text] [doi: 10.1186/1756-0500-3-238] [Medline: 20831836] 9. Evertsen G, Brox E. Acceptance of a targeted exergame program by elderly. 2015 Presented at: Proceedings from the 13th Scandinavian Conference on Health Informatics; 2015; Tromso, Norway p. 12-15. 10. Brox E, Luque L, Evertsen G, Hernandez JEG. Exergames for elderly: social exergames to persuade seniors to increase physical activity. 2011 Presented at: 5th International Conference on Pervasive Computing Technologies for Healthcare; 2011; Dublin, Ireland p. 546-549. [doi: 10.4108/icst.pervasivehealth.2011.246049] 11. Brox E, Evertsten G, Åsheim-Olsen H, Burkow T, Vognild L. Experience from long-term exergaming with elderly. In: Proceedings of the 18th International Academic Mindtrek Conference. New York: ACM; 2014:216-220. [doi: 10.1145/2676467.2676483] http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al 12. Bird M, Clark B, Millar J, Whetton S, Smith S. Exposure to “Exergames” increases older adults' perception of the usefulness of technology for improving health and physical activity: a pilot study. JMIR Serious Games 2015;3(2):e8 [FREE Full text] [doi: 10.2196/games.4275] [Medline: 26614263] 13. Billis A, Konstantinidis E, Mouzakidis C, Tsolaki M, Pappas C, Bamidis P. A game-like interface for training seniors’ dynamic balance and coordination. IFMBE Proceedings 2010:691-694. 14. Konstantinidis EI, Billis A, Hlauschek W, Panek P, Bamidis PD. Integration of cognitive and physical training in a smart home environment for the elderly people. Stud Health Technol Inform 2010;160(Pt 1):58-62. [Medline: 20841650] 15. Jung Y, Li W, Gladys C, Lee K. Games for a better life: Effects of playing Wii games on the well-being of seniors in a long-term care facility. 2009 Presented at: Proceedings of the Sixth Australasian Conference on Interactive Entertainment; 2009; Sydney, Australia p. 0-5. 16. Rendon AA, Lohman EB, Thorpe D, Johnson EG, Medina E, Bradley B. The effect of virtual reality gaming on dynamic balance in older adults. Age Ageing 2012 Jul;41(4):549-552 [FREE Full text] [doi: 10.1093/ageing/afs053] [Medline: 22672915] 17. Brox E, Evertsen G, Åsheim-Olsen H, Hors-Fraile S, Browne J. Experience with a 3D Kinect exergame for elderly. 2015 Presented at: Proceedings of the 8th International Conference on Health Informatics; 2015; Lisbon, Portugal p. 12-15. [doi: 10.5220/0005165602310238] 18. Konstantinidis ST, Brox E, Kummervold PE, Hallberg J, Evertsen G, Hirche J. Online social exergames for seniors: a pillar of gamification for clinical practice. In: Novák D, Tulu B, Brendryen H, editors. Handbook of Research on Holistic Perspectives in Gamification for Clinical Practice. Hershey, PA: IGI Global; Oct 21, 2015:245-276. [doi: 10.4018/978-1-4666-9522-1.ch012] 19. van der Abeele AA, Van Rompaey RV. Introducing human-centered research to game design: designing game concepts for and with senior citizens. 2006 Presented at: CHI '06 Extended Abstracts on Human Factors in Computing; 2006; Montreal, Canada p. 1469-1474. [doi: 10.1145/1125451.1125721] 20. Gerling K, Schild J, Masuch M. Exergame design for elderly users: the case study of SilverBalance. 2010 Presented at: Proceedings of the 7th International Conference on Advances in Computer Entertainment Technology; 2010; Taipei, Taiwan p. 66-69. 21. Ergonomics of human-system interaction—Part 210: Human-centred design for interactive systems. URL: https://www. iso.org/obp/ui/#iso:std:iso:9241:-210:ed-1:v1:en [accessed 2016-12-16] 22. Karat J, Karat CM. The evolution of user-centered focus in the human-computer interaction field. IBM Syst J 2003;42(4):532-541. [doi: 10.1147/sj.424.0532] 23. Sebe N. Human-centered computing. In: Handbook of Ambient Intelligence and Smart Environments. New York: Springer; 2010:349-370. [doi: 10.1007/978-0-387-93808-0_13] 24. Proffitt R, Lange B. User centered design and development of a game for exercise in older adults. Int J Technol Knowl Soc 2012;8(5):112. 25. van der Weegen S, Verwey R, Spreeuwenberg M, Tange H, van der Weijden T, de Witte WL. The development of a mobile monitoring and feedback tool to stimulate physical activity of people with a chronic disease in primary care: a user-centered design. JMIR Mhealth Uhealth 2013;1(2):e8 [FREE Full text] [doi: 10.2196/mhealth.2526] [Medline: 25099556] 26. Vredenburg K, Mao J, Smith P, Carey T. A survey of user-centered design practice. 2002 Presented at: Proceedings of the SIGCHI Conference on Human Factors in Computing Systems; 2002; Minneapolis, MN p. 3460-3478. [doi: 10.1145/503376.503460] 27. Gregor P, Newell A, Zajicek M. Designing for dynamic diversity: interfaces for older people. 2002 Presented at: Proceedings of the 5th international ACM conference on Assistive technologies; 2002; Edinburgh, UK p. 151-156. [doi: 10.1145/638249.638277] 28. Thimbleby H. Understanding user centred design (UCD) for people with special needs. In: Miesenberger K, editor. Computers Helping People with Special Needs. Berlin: Springer; 2008. 29. Zajicek M. Successful and available: interface design exemplars for older users. Interact Comput 2004:411-430. [doi: 10.1016/j.intcom.2004.04.003] 30. Billis A, Konstantinidis E, Ladas A, Tsolaki M, Pappas C, Bamidis P. Evaluating affective usability experiences of an exergaming platform for seniors. Biomed Eng 2011:1-4. [doi: 10.1109/IWBE.2011.6079048] 31. Dickinson A, Arnott J, Prior S. Methods for human-computer interaction research with older people. Behav Inf Technol 2007;26(4):343-352. [doi: 10.1080/01449290601176948] 32. Holt B. Creating senior-friendly Web sites. Issue Brief Cent Medicare Educ 2000;1(4):1-8. [Medline: 11817407] 33. AgeLight. Interface Design Guidelines for Users of all Ages. 2001. URL: http://www.agelight.com/webdocs/designguide. pdf [accessed 2016-02-15] [WebCite Cache ID 6fJZssXUM] 34. Kurniawan S, Zaphiris P. Research-derived Web design guidelines for older people. 2005 Presented at: Proceedings of 7th international ACM SIGACCESS Conference on Computers and Accessibility; 2005; Baltimore, MD p. 129-135. [doi: 10.1145/1090785.1090810] 35. National Institute on Aging, National Library of Medicine. Making your Web site senior friendly: a checklist. 2002. URL: https://www.nlm.nih.gov/pubs/checklist.pdf [accessed 2016-02-15] [WebCite Cache ID 6fJaI60tL] http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al 36. Bamidis PD, Gabarron E, Hors-Fraile S, Konstantinidis E, Konstantinidis S, Rivera O. Gamification and behavioral change: techniques for health social media. In: Syed-Abdul S, Gabarron E, Lau A, editors. Participatory Health Through Social Media. London: Elsevier; Jun 17, 2016:112-135. 37. Chrisnell D, Redish J. Designing web sites for older adults: expert review of usability for older adults at 50 Web sites. AARP. 2005. URL: http://www.redish.net/images/stories/PDF/AARP-50Sites.pdf [accessed 2016-12-16] [WebCite Cache ID 6mo2iujhA] 38. Kurniawan S, King A, Evans D, Blenkhorn P. Personalising Web page presentation for older people. Interact Comput 2006 May;18(3):457-477. [doi: 10.1016/j.intcom.2005.11.006] 39. Fidgeon T. Usability for Older Web Users. WebCredible. 2006. URL: http://www.webcredible.com/blog/ usability-older-web-users/ [accessed 2016-02-15] [WebCite Cache ID 6fJbSkwzL] 40. Arch A, Abou-Zahra S. Developing websites for older people: how web content accessibility guidelines (WCAG) 2.0 applies. Web Accessibility Initiative. 2010. URL: https://www.w3.org/WAI/older-users/developing.html [accessed 2016-02-15] [WebCite Cache ID 6fJbgt5SI] 41. Awad M, Ferguson S, Craig C. Designing games for older adults: an affordance-based approach. 2014 Presented at: IEEE 3nd International Conference on Serious Games and Applications for Health (SeGAH); 2014; Rio de Janeiro, Brazil URL: http://doi.org/10.1109/SeGAH.2014.7067103 [doi: 10.1109/SeGAH.2014.7067103] 42. Hors Fraile S, Browne J, Brox E, Evertsen G. Suitability analysis of commercial open-source driven motion sensor devices applied to exergames for the elderly. Ambient Assisted Living Forum Eindhoven 2012. 43. Faulkner L. Beyond the five-user assumption: benefits of increased sample sizes in usability testing. Behav Res Methods Instrum Comput 2003 Aug;35(3):379-383. [Medline: 14587545] 44. Nielsen Norman Group. Why You Only Need to Test With 5 Users. 2000. URL: https://www.nngroup.com/articles/ why-you-only-need-to-test-with-5-users/ [accessed 2016-11-29] [WebCite Cache ID 6mOEaiOUa] 45. Spool J, Schroeder W. Testing web sites: five users is nowhere near enough. 2001 Presented at: CHI '01 Extended Abstracts on Human Factors in Computing Systems; 2001; Seattle. [doi: 10.1145/634067.634236] 46. Macefield R. How to specify the participant group size for usability studies: a practitioner's guide. J Usability Studies 2009;5(1):34-45 [FREE Full text] 47. Baek EO, Cagiltay K, Boling E, Frick T. User-centered design and development. In: Spector JM, Merrill MD, van Merrienboer JJ, Driscoll MF, editors. Handbook of Research on Educational Communications and Technology, Third edition. London: Routledge; 2008:659-570. 48. Redish J, Chisnell D. Designing web sites for older adults: a review of recent research. AARP. 2004. URL: http://www. redish.net/images/stories/PDF/AARP-LitReview2004.pdf [accessed 2016-02-15] [WebCite Cache ID 6fJcYH312] 49. Hayes V, Morris J, Wolfe C, Morgan M. The SF-36 health survey questionnaire: is it suitable for use with older adults? Age Ageing 1995 Mar;24(2):120-125. [Medline: 7793333] 50. Iacono I, Marti P. Engaging older people with participatory design. 2014 Presented at: Proceedings of the 8th Nordic Conference on Human-Computer Interaction: Fun, Fast, Foundational; 2014; Helsinki, Finland p. 859-864. [doi: 10.1145/2639189.2670180] Abbreviations UCD: user-centered design Edited by G Eysenbach; submitted 22.06.16; peer-reviewed by ML Bird, M Immonen, C Giraud-Carrier; comments to author 25.07.16; revised version received 30.11.16; accepted 30.11.16; published 11.01.17 Please cite as: Brox E, Konstantinidis ST, Evertsen G User-Centered Design of Serious Games for Older Adults Following 3 Years of Experience With Exergames for Seniors: A Study Design JMIR Serious Games 2017;5(1):e2 URL: http://games.jmir.org/2017/1/e2/ doi: 10.2196/games.6254 PMID: 28077348 ©Ellen Brox, Stathis Th Konstantinidis, Gunn Evertsen. Originally published in JMIR Serious Games (http://games.jmir.org), 11.01.2017. 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, http://games.jmir.org/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Brox et al 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/2017/1/e2/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e2 | p. 14 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Jan 11, 2017

Keywords: user studies; usability testing; gestural input; user-centred design; accessibility; consumer health; exergames; participatory design; lessons learnt

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