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Thesis:Author(YearofSubmission)"Fullthesistitle",UniversityofSouthampton,nameofthe

UniversityFacultyorSchoolorDepartment,PhDThesis,pagination.

Data:Author(Year)Title.URI[dataset]

UNIVERSITYOFSOUTHAMPTON

FACULTYOFPHYSICALSCIENCESANDENGINEERING

SchoolofElectronicandComputerScience

GamificationforTheSelf-managementofChronicIllnesses

by

AlaaAbdullahAlMarshedi

Thesisforthedegreeofdoctorofphilosophy

July_2017

UNIVERSITYOFSOUTHAMPTON

ABSTRACT

FACULTYOFPHYSICALSCIENCESANDENGINEERING

SchoolofElectronicandComputerScience

ThesisforthedegreeofDoctorofPhilosophy

GAMIFICATIONFORTHESELF-MANAGEMENTOFCHRONIC-ILLNESSES

AlaaAbdullahAlMarshedi

Theuseofgamificationinhealthcarehasbeenreceivingagreatdealofattentioninboth

academicresearchandindustry,butthereareyettobeframeworksandguidelinesforits

implementation.Thisthesisfocusesontheuseofgamificationintheself-managementofchronic

illnesses,inparticular,diabetes.Thethesispresentsanovelframeworkandasetofguidelinesfor

developerstoimplementgamificationinthisarea.

Theframework,calledTheWheelofSukr,combineselementsfromself-managementpractices,

gameelements,andbehaviourchangemethods.Itconsistsof28elementsgroupedunder8

themes.Theframeworkhasbeenvalidatedusingamixed-methodapproachbyconducting

interviewswithexpertsfromthefieldsofmedicine,psychology,games,andgamification.

Moreover,aquestionnairewascompletedbyindividualswithdiabetesinordertomeasuretheir

attitudestowardsthethemesoftheframework.Thisstudyindicatedanoverallacceptanceofthe

notionofgamificationintheself-managementofdiabetes.

Aftervalidation,asetofguidelinesbasedontheframeworkwasintroduced.Theguidelineswere

validatedusingamulti-methodapproachwhereexpertinterviewsandfocusgroupsessionswere

conducted.Theguidelinesreceivedsupportfromtheexperts,whoagreedthattheyaccurately

reflecttheframeworkandthatdeveloperscanpotentiallyusethemtocreategamifiedself-

managementappsforchronicillnesses.Moreover,developerswhoparticipatedinthefocus

groupsessionswelcomedtheguidelines.Theyfoundthemtobeclear,useful,andimplementable.

Furthermore,theywereabletosuggestseveralwaysofgamifyinganon-gamifiedself-

managementappwhentheywerepresentedwithone.Thefindingssuggestthattheguidelines

introducedinthisresearchareclear,useful,andreadytobeimplementedforthecreationofself-

managementappsthatusethenotionofgamificationasdescribedintheWheelofSukr

framework.

i

TableofContents

TableofContents............................................................................................................i

ListofTables..................................................................................................................v

ListofFigures...............................................................................................................vii

DECLARATIONOFAUTHORSHIP.....................................................................................ix

Acknowledgements.......................................................................................................xi

Chapter1: Introduction........................................................................................1

1.1 Peer-ReviewedContributions.................................................................................4

Chapter2: LiteratureReview................................................................................7

2.1 Gamification............................................................................................................7

2.1.1 GameElementsandDynamics................................................................10

2.1.2 CulturalandSocialContext.....................................................................13

2.1.3 GamificationandSeriousGames............................................................14

2.1.4 GamificationApplicationFields...............................................................16

2.1.5 GamificationFrameworks.......................................................................23

2.2 GamificationandHumanPsychology....................................................................25

2.2.1 Motivation...............................................................................................26

2.2.2 BehaviourChange...................................................................................31

2.3 GamificationforHealthcare..................................................................................33

2.3.1 ChronicIllnessesandSelf-management.................................................35

2.3.2 GamifyingSelf-managementofChronicIllnesses...................................37

2.3.3 TheGapintheLiteratureanditsImportance:........................................41

2.4 Summary...............................................................................................................42

Chapter3: Methodology.....................................................................................45

3.1 OverviewofResearchMethods............................................................................45

3.2 ResearchProcess...................................................................................................49

3.3 Summary...............................................................................................................52

Chapter4: FrameworkanditsValidation............................................................55

ii

4.1 Background...........................................................................................................55

4.2 FrameworkDesignProcess...................................................................................56

4.2.1 TheElementsandThemes......................................................................57

4.3 TheWheelofSukrFramework..............................................................................63

4.4 ValidationoftheWheelofSukr:Mixed-Methods................................................64

4.5 Study1:ExpertInterviews....................................................................................65

4.5.1 Interviews DesignandProcess................................................................65

4.5.2 InterviewsFindings.................................................................................68

4.6 Study2:TheQuestionnaire...................................................................................77

4.6.1 QuestionnaireDesignandProcess..........................................................77

4.6.2 QuestionnaireResults.............................................................................85

4.7 Discussion..............................................................................................................97

4.8 Summary.............................................................................................................103

Chapter5: TheSetofGuidelinesanditsValidation...........................................105

5.1 TheTransitionfromtheFrameworktotheGuidelines.......................................105

5.2 TheWheelofSukrGuidelines.............................................................................114

5.3 ValidationoftheGuidelines:Multi-Methods......................................................122

5.4 Study1:ExpertInterviews..................................................................................123

5.4.1 InterviewsDesignandProcess..............................................................123

5.4.2 InterviewsFindings...............................................................................124

5.5 Study2:FocusGroupInterviews.........................................................................130

5.5.1 FocusGroupInterviewsDesignandProcess.........................................130

5.5.2 FocusGroupInterviewsFindings..........................................................131

5.6 Discussion............................................................................................................135

5.7 Summary.............................................................................................................137

Chapter6: Conclusions......................................................................................139

6.1 Contributions......................................................................................................143

6.2 Futurework.........................................................................................................144

AppendixA.................................................................................................................149

iii

AppendixB.................................................................................................................151

AppendixC.................................................................................................................156

ListofReferences.......................................................................................................159

v

ListofTables

Table2-1Similaritiesbetweengamemechanicsandhumandesires(Bunchball,2012)............12

Table2-2PersuasiveStrategies(Cugelman,2013).....................................................................13

Table2-3Tenmostpopulargamificationelements(Cugelman,2013)......................................13

Table2-4Differencesbetweenvideogames,seriousgamesandgamification..........................15

Table2-527Gamificationappsclassifiedinto10categories.....................................................22

Table3-1DifferencesbetweenQuantitativeandQualitativeMethods.....................................49

Table4-1Alistofelementssynthesisedfromtheliteratureonthehealthcareofchronicillnesses

........................................................................................................................57

Table4-2Alistofelementssynthsisedfromgamificationliterature.........................................58

Table4-3Alistofelementssynthesisedfrombehaviourandgamificationliterature...............59

Table4-4TheWheelofSukrThemes..........................................................................................62

Table4-5InterviewExperts.........................................................................................................66

Table4-6Thequestionnaire.......................................................................................................81

Table4-7G*PowerValues..........................................................................................................83

Table4-8DatafromPart1oftheQuestionnaire........................................................................87

Table4-9FrequencyTable..........................................................................................................88

Table4-10TheStatisticalAnalysisoftheQuestionnaire(SPSS)................................................89

Table5-1SectionsoftheGuidelines.........................................................................................112

Table5-2ScoreTable(Ratingsfrom0-9)..................................................................................131

vii

ListofFigures

Figure2-1Thedifferencebetweengamingandplaying(AdaptedfromDeterding,Dixon,etal

2011).................................................................................................................9

Figure2-2ExtrinsicMotivationClassification(adaptedfrom(RyanandDeci,2000))................27

Figure2-3TheFlowTheory:Challenge–SkillBalance(Adaptedfrom(Csikszentmihalyi,1990))30

Figure2-4Maslow'sHierarchyofHumanNeeds........................................................................31

Figure2-5Fogg'sBehaviourModel.............................................................................................32

Figure2-6Tinyhabits..................................................................................................................33

Figure3-1ResearchProcess........................................................................................................51

Figure4-1TheThreeMainAreasofResearch............................................................................56

Figure4-2TheEightThemesandtheirElements........................................................................60

Figure4-3TheWheelofSukr......................................................................................................64

Figure4-4ComponentsofTriangulationforFrameworkValidation..........................................64

Figure4-5ParticipantsAgeGroup..............................................................................................86

Figure5-1ComponentsofTriangulationofGuidelinesValidation...........................................122

ix

DECLARATIONOFAUTHORSHIP

I,AlaaAbdullahAlmarshedi

declarethatthisthesisandtheworkpresentedinitaremyownandhasbeengeneratedbymeas

theresultofmyownoriginalresearch.

GAMIFICATIONFORTHESELF-MANAGEMENTOFCHRONIC-ILLNESSES

Iconfirmthat:

1. Thisworkwasdonewhollyormainlywhileincandidatureforaresearchdegreeatthis

University;

2. Whereanypartofthisthesishaspreviouslybeensubmittedforadegreeoranyother

qualificationatthisUniversityoranyotherinstitution,thishasbeenclearlystated;

3. WhereIhaveconsultedthepublishedworkofothers,thisisalwaysclearlyattributed;

4. WhereIhavequotedfromtheworkofothers,thesourceisalwaysgiven.Withtheexception

ofsuchquotations,thisthesisisentirelymyownwork;

5. Ihaveacknowledgedallmainsourcesofhelp;

6. Wherethethesisisbasedonworkdonebymyselfjointlywithothers,Ihavemadeclear

exactlywhatwasdonebyothersandwhatIhavecontributedmyself;

7. Partsofthisworkhavebeenpublishedas:

• AlMarshedi,Alaa,Wills,GaryandRanchhod,Ashok(2016)Gamifyingself-managementof

chronicillnesses:amixed-methodsstudyJMIRSeriousGames,4,(2),pp.1-11.

(doi:10.2196/games.5943).(PMID:27612632).

• AlMarshedi,Alaa,Wills,GaryandRanchhod,Ashok(2017)GuidelinesfortheGamification

ofSelf-ManagementofChronicillnesses:Multi-methodstudy.JMIRSeriousGames,5,(2),

(doi:10.2196/games.7472).(PMID:28500018).

• AlMarshedi,Alaa,Wills,GaryandRanchhod,ashok(2015)ThewheelofSukr:a

frameworkforgamifyingdiabetesself-managementinSaudiArabiaThe5thInternational

ConferenceonCurrentandFutureTrendsofInformationandCommunication

TechnologiesinHealthcare(ICTH2015)(doi:10.1016/j.procs.2015.08.370).

• AlMarshedi,Alaa,Wills,GaryandRanchhod,Ashok(2014)Gamificationtoimprove

adherencetodiabetictreatmentinSaudiArabiaAtInternationalConferenceon

InformationSociety(i-Society2014),UnitedKingdom.10-12Nov2014.2pp.

• Almarshedi,Alaa,Wills,Gary,Wanick,VanissaandRanchhod,Ashok(2017)Gamification

andbehaviour.In,Gamification:Morethanjustgames!UsingGameElementinSerious

Contexts.Springer

x

Signed: ..............................................................................................................................................

Date: ..............................................................................................................................................

xi

Acknowledgements

First,Iwouldliketothankmyparents,husband,andfamilyfortheirconstantencouragementand

support,andespeciallymyhusbandforhispatienceandunderstandingthroughoutmyPhD

journey.

IamverygratefultomymainsupervisorDr.GaryWillsforhissupportandguidance.Iwouldalso

liketothankmycolleaguesforthemanydiscussionsthatwehadthroughoutourstudies.

Finally,IacknowledgethesponsorshipbytheSaudiGovernmentScholarshipProgram.

Chapter1

1

Chapter1: Introduction

Gamificationistheuseofgameelementsbeyondthescopeofentertainment.Itincorporatesthe

engagingandrewardingaspectsofgamesintootherareas(e.g.healthcareandeducation)to

increasemotivationandengagement,andinfluencebehaviour.Gamificationisconsideredoneof

thepopularemergingtechnologiesinindustry(LeHongandFenn,2013).Itstartedaroundten

yearsagoinindustry,whereafewcompaniesprovidedgamificationplatformstoenhancethe

motivationandengagementofemployees,andtocreateashiftinthebehaviourofconsumers

(Dale,2014).Eversince,ithasbeenreceivingagreatdealofattentioninindustryandiscurrently

appliedindifferentareassuchasinbusiness,marketing,education,andhealthcare.Accordingto

arecentreport,gamificationisestimatedtobean11billionUSDindustryin2020(Marketsand

Markets2016).Furthermore,therehasbeenagrowinginterestingamificationintheacademic

literatureoverthepastfewyears(SeabornandFels,2014).Itisaninterdisciplinaryfieldofstudy

wheretheresearchrangesfromstudyingitseffectstoprovidingframeworksandguidelinesforits

applicationinspecificareas(Simões,RedondoandVilas,2012;Nguyen,2015;Nackeand

Deterding,2017).

Moreover,theadvancementintechnologies,smartphones,andtrackingtechnologiescouldhave

playedaroleintheincreasedinterestingamification,specificallyforhealthcarepurposes(Swan,

2009;Deterding,2012).Itcouldbeusedtofacilitateuser-centredhealthcareandinfluencehealth

behaviours.Healthcareencompassesmanyareassuchasfitnessandself-management.In

particular,theself-managementofchronicillnessesisanareawheretherearemanychallenges

andopportunities.

Oneofthemajorchronicillnessesisdiabetes.Diabetesiswidespreadinmanycountries

throughouttheworldanditsprevalenceishighinmanyplaces.Thisillnessrequiresextensive

self-careandtheself-managementofseveralaspectsofdailylife.Thisisrepetitiveandcouldbe

challengingtosomeindividuals.Althoughthereareelectroniclogbooksandonlineforumsfor

individualswithdiabetes,thesetoolsandcommunitiesmightnotbeengagingnormotivatingto

users.Thus,itisofinteresttoenhancethemotivationofindividualswithdiabetes,increasetheir

engagementwiththeirdailyself-managementtasks,andmakethisdailyprocesseasierand

perhapsanenjoyableexperience.Thisiswheregamificationmayplayamajorrole.

Thewaythatgamificationtriestoenhancemotivationandengagement,andinfluencebehaviour

isbasedonanumberofpsychologicaltheories.Thesetheoriesaddressanumberofaspects:First,

motivation,itstypes,andhowpeoplearemotivated.Second,thecircumstancescausingdifferent

Chapter1

2

typesofbehaviourandhowtoencourageuserstocarryoutcertaintasks.Third,howtosustain

themotivationandengagementofusersandtoachievethedesiredeffectsofgamification.

Therearemanyaspectsofgamificationthatincorporatethesetheories.Forexample,areward

systemthatisbasedonpoints,badgesandleaderboardsmayextrinsicallymotivateusers,while

creatinganexperiencethatenhancesfeelingsofmastery,purpose,andautonomycanintrinsically

motivateandencouragethemtocarryoutthedailytasksofself-management.

Whilegamificationispromisinginthisarea,surprisingly,incorporatinggamificationintotheself-

managementofchronicillnesseshasnotbeenstudiedagreatdealintheliterature.Inparticular,

therearenoframeworksorguidelinesthatcombineelementsfromthegamification,behaviour

change,andself-managementliteraturetoaidthedevelopmentofgamifiedself-management

appsforindividualswithchronicillnessessuchasdiabetes.Tofillthisgapintheliterature,this

thesiswillprovidethefirstframeworkforthegamificationoftheself-managementofchronic

illnesses.Moreover,asetofguidelinesthataiddevelopersinthegamificationoftheself-

managementofchronicillnesseswillbeproposed.

Theframeworkwillsynthesiseelementsfromtheliteratureongamification,behaviourchange,

andtheself-managementofchronicillnessesespeciallydiabetes.Next,toensurethatthe

frameworkisvalidforsuchanarea,itwillbevalidatedusingamixed-methodapproach.In

particular,medicaldoctors,psychologists,andgamificationexpertswillbeinterviewedtoobtain

theirinsightsontheframework.Inaddition,individualswithdiabetes(basedinSaudiArabia)will

participateinaquestionnairethataimstomeasuretheirattitudestowardstheconceptscovered

bytheframework.Theresultsofbothstudieswillbeusedtovalidatetheframework.

Theframeworkwillthenbetranslatedintoasetofguidelinesthatcanbeappliedpracticallyby

developers.Theguidelineswillcontaindefinitions,goals,adescription,andanapplicationtoaid

developersincreatinggamifiedself-managementappsforchronicillnesses.Tovalidatethe

guidelines,amulti-methodapproachwillbeused.Inparticular,thesetofguidelineswillbe

assessedbyexpertinterviewstoensurethattheyrepresenttheframeworkaccuratelyand

comprehensively.Theguidelineswillbemodifiedaccordingtothefeedbackoftheexperts.The

modifiedversionoftheguidelineswillbediscussedwithdevelopersinfocusgroupinterviews.

Thepurposeofthefocusgroupdiscussionswithdevelopersistwo-fold:thefirstaimistocollect

theirviewsontheclarityusefulness,andeaseofimplementationoftheguidelines.Thesecond

aimistotestiftheycouldthinkofpracticalwaystogamifyappsbasedontheguidelines.The

resultsofbothstudieswillbeusedtovalidatethesetofguidelines.

Chapter1

3

Theoverallstructureofthethesistakestheformofsixchapters:

Chapter1providesanintroductiontotheoverallthesisandalistofapeer-reviewed

contributionsbasedonthisPhDwork.

AliteraturereviewispresentedinChapter2inwhichtheauthorexplorestheliteratureinthe

threemainareasofresearchinthisthesis:gamification,behaviourchange,andtheself-

managementofchronicillnesses(specificallydiabetes).

Thechapterstartswithareviewofgamificationandincludesitsdefinitionandthecultural

contextwhichhasledtoitspopularity.Moreover,similarconceptstogamificationandafocuson

itsapplicationsandthefieldsinwhichithasbeenimplementedwillalsobediscussed.

Thechapterthenpresentsareviewonmotivation,ittypes,andhowitisusedingamification.

Thissectionofthechapteralsocoversanumberofbehaviourmodelsandtheoriesthatarelinked

togamificationandwouldbeofinterestingamificationforhealthcare.

Finally,thechapterpresentsasectionontheuseofgamificationinhealthcareandtheself-

managementofdiabetes.

Chapter3providesthemethodologyusedinthisthesis.Thechapterstartsbygivinganoverview

oftheresearchmethodsemployed.Itthenexplainsthespecificresearchmethodstobeusedin

thevalidationoftheproposedframework,namelyTheWheelofSukr.Thiscoverstheuseof

triangulationandmixed-methodstovalidatetheframework,whichconsistsofexpertinterviews

andaquestionnaireforpotentialusers.

Afterthat,thechaptergoesontopresenttheresearchmethodsusedinthevalidationofthe

proposedguidelines,namelyTheWheelofSukrGuidelines.Thiscoverstheuseofamulti-method

approachofqualitativeresearchmethods.Thevalidationoftheguidelinesinvolvedexpert

interviewsandfocusgroupsessions.

InChapter4theframeworkanditsvalidationwillbepresented.Thechapterstartsbydiscussing

theframeworkdesignprocessanditscomponents.Theresearchmethodsemployedforthe

validationoftheframeworkarepresented.Thevalidationprocessconsistsoftwostudies.First,

theexpertinterviewsandthefindingsarepresented.Then,thequestionnaireandtheresultsare

presented.Finally,thechapterendswithadiscussionofthefindingsandresultsofbothstudies.

Chapter5presentsthesetofguidelinesandtheirvalidation.Thechapterstartswiththe

transitionprocessfromtheframeworktothecreationoftheguidelines.Then,theresearch

methodsthatareusedtovalidatethesetofguidelinesarepresented.Thevalidationprocess

Chapter1

4

consistsoftwoqualitativestudies.First,theexpertinterviewsandthefindingsarepresented.

Then,theguidelineswillbemodifiedpriortoconductingthesecondstudy.Afterthat,thesecond

studyinvolvingfocusgroupinterviewswillbepresentedwithitsfindings.Lastly,thefindingsof

bothstudieswillbeusedtovalidatethesetofguidelines.

Finally,inChapter6aconclusiontothethesisisprovidedandanoverviewoffutureresearch

directionswillbepresented.Thechapterwillalsopresentresearchimplicationsandlimitations.

1.1 Peer-ReviewedContributions

Thisthesiscombinesanumberofresearchresults,whichhavebeenpublishedinpeer-reviewed

journals,conferences,orbooks.

BookSection:

Almarshedi,Alaa,Wills,Gary,Wanick,VanissaandRanchhod,Ashok(2017)Gamificationand

behaviourIn,Gamification:Morethanjustgames!UsingGameElementsinSeriousContexts.

Springer(Citation=1)

JournalPapers:

AlMarshedi,Alaa,Wills,GaryandRanchhod,Ashok(2016)Gamifyingself-managementofchronic

illnesses:amixed-methodsstudyJMIRSeriousGames,4,(2),pp.1-11.(doi:10.2196/games.5943).

(PMID:27612632).(Citation=4)

AlMarshedi,Alaa,Wills,GaryandRanchhod,Ashok(2017)GuidelinesfortheGamificationofSelf-

ManagementofChronicillnesses:Multi-methodstudy.JMIRSeriousGames,5,(2),

(doi:10.2196/games.7472).(PMID:28500018).

AlMarshedi,Alaa,Wills,Gary,Wanick,VanissaandRanchhod,Ashok(2015)SGI:aframeworkfor

increasingthesustainabilityofgamificationimpactInternationalJournalforInfonomics,8,(1/2),

pp.1044-1052.(Citation=11)

Conferences:

AlMarshedi,Alaa,Wills,GaryandRanchhod,ashok(2015)ThewheelofSukr:aframeworkfor

gamifyingdiabetesself-managementinSaudiArabiaThe5thInternationalConferenceonCurrent

andFutureTrendsofInformationandCommunicationTechnologiesinHealthcare(ICTH2015)

(doi:10.1016/j.procs.2015.08.370).(Citation=4)

Chapter1

5

AlMarshedi,Alaa,Wills,GaryandRanchhod,Ashok(2014)Gamificationtoimproveadherenceto

diabeteictreatmentinSaudiArabia.AtInternationalConferenceonInformationSociety(i-Society

2014),UnitedKingdom.10-12Nov2014.2pp.

AlMarshedi,Alaa,Wanick,Vanissa,Wills,GaryandRanchhod,Ashok(2014)Towardsasustainable

gamificationimpactAtInternationalConferenceonInformationSociety(i-Society2014),United

Kingdom.10-12Nov2014.(Citation=4)

Chapter2

7

Chapter2: LiteratureReview

Thischapterpresentsareviewontheliteratureofthethreemainareasofresearchinthisthesis.

Thesearegamification,motivationandbehaviourchangemethods,andtheself-managementof

chronicillnesses,specificallydiabetes.Thechapterstartswithdefininggamification,givesa

backgroundontheculturalandsocialcontextthathasledtoitsrise,discussesasimilarconcept,

andprovidesanoverviewofsomegamificationappsandframeworks.Thesecondpartofthe

chaptercoversthepsychologyofgamification.Itdiscussesthedifferenttypesofmotivationand

theirrelevancetogamification,andbehaviourchangemethodsthatcanbeutilisedinconjunction

withgamification.Thethirdpartofthechaptercoversgamificationinhealthcare.Itstartsby

givingabackgroundtochronicillnesses,theself-managementofchronicillnesses,andtheroleof

communityandpeersupport.Then,theuseofgamificationforchronicillnesses,specifically

diabetes,isdiscussed.

2.1 Gamification

Thenotionthatgamesandworkcannotcoexisthaschangedinrecentyears.Gameshave

surpassedtheirtraditionalboundaries(Deterding,Sicart,etal.,2011),andarenolonger

constrainedtoonegenderorage(Griffiths,DaviesandChappell,2004;Williams,YeeandCaplan,

2008;EntertainmentSoftwareAssociation,2016).Arecentstudyshowsthatthemajority(63%)of

householdsintheUSalonehaveatleastonepersonwhoplaysvideogamesregularly

(EntertainmentSoftwareAssociation,2016).Moreover,millennialshavegrownupplayinggames,

whichmakethemaccustomedtothenatureofgamesintermsofpursuingrewardsandseeking

moreengagementfromexperiences(AndersonandRainie,2012).Thesefactorsaswellasthe

availabilityofcheaptrackingtechnologiesandafocusonindividualandbehaviouralanalytics

haveledtotheriseofgamification(Deterding,2012).

Differentdefinitionsexistforgamificationinindustryandacademia(Llagostera,2012;Seaborn

andFels,2014).However,themostciteddefinitionandtheoneusedinthisthesisisthedefinition

introducedby(Deterding,Dixon,etal.,2011;Deterding,Sicart,etal.,2011):

“Theuseofgameelementsinnon-gamingcontexts”

Theaimofgamificationistoengage,motivate,andinfluencethebehaviourofusers(Deterding,

Sicart,etal.,2011;HamariandKoivisto,2015).Thisisachievedinafunway,benefitingfrom

theoriesusedingamessuchasflowtheory,andtheinnateurgeinusersforrecognitionand

instantpositivefeedback(discussedinSection2.2.1.3).Gamificationdrawsheavilyfromgames

Chapter2

8

andhumanpsychology.Forexample,theelementsthatareconsideredtomakegamessuccessful,

accordingtoReevesandRead(2009),namelygoals,feedback,points,levels,competitions,

teamworkandself-representation(e.g.Avatars)whichareimplementedinastorylinethat

motivatesusers.

Someresearcherssaythattheterm“gamification”firstappearedin2008,thoughitdidnotgain

momentumuntil2010(Deterdingetal.,2011).However,thetermwascoinedbyNickPellingin

2002/2003(Hagglund,2012;Dale,2014).Thereisanon-goingdebateontheterm“gamification”

andothertermshavebeenusedinplaceofitsuchas“gamefuldesign”(Deterdingetal.,2011)

and“gamefulness”(McGonigal,2011).However,theterm“gamification”isstillthemost

commonlyused(Deterdingetal.,2011).Thisdebatecouldbearesultofthefactthatitisa

relativelynewfield.

Gamificationisderivedfromgames,whichfallunderthebroadercategoryofplay(Zimmerman

andSalen,2003;Deterding,Dixon,etal.,2011).Caillios(2001),theFrenchphilosopher,who

studiedgamesandplay,consideredthemtwooppositeformsofplayactivities.Playisdescribed

asbeingspontaneousandimaginative,withimprovisationalbehavioursandmeanings.Onthe

otherhand,gamesarecharacterizedbyrules,instructions,andcompetitionstoreachadefined

goaloroutcome(ZimmermanandSalen,2003;Juul,2005).Thisdifferentiationbetweenplayand

gameinfluencedthedefinitionofgamificationinworkbyDeterding,Dixon,etal(2011).More

specifically,toys,forexample,representthewholeconceptofplaying.Ononehand,playful

designrepresentsonlypartsoftheconceptofplay.Ontheotherhand,gamingtakenasawholeis

manifestedingames,orseriousgames,whereasgamificationrepresentspartsoftheconceptof

gamingwhichareusedinnon-gamingcontextssuchashealthcare.Thiscategorisationhasbeen

illustratedbyDeterding,Dixon,etal.(2011)inFigure2-1.

Chapter2

9

Figure2-1Thedifferencebetweengamingandplaying(AdaptedfromDeterding,Dixon,etal

2011)

Eventhoughtheterm“gamification”isnew,theconceptitselfisnot.Theuseofpoints,badges,

leaderboards,andcompetitionsintheworkplacehadalreadybeenintroducedinthepastwith

similargoalstogamification(Nelson,2012).Indeed,theuseofrewardsisnotlimitedtothe

modernday;anditextendsfarbackintohistory.Peoplethroughouthistoryunderstoodthe

impactofrewards,whichleavepeoplefeelinghappy(Schultz,2006).Theserewardscouldbeof

materialformorintheformofbadges,whichconveystatus.

Theuseofrewardsandincentivesstillexistsinmanyaspectsofourlives.Inschoolforexample,

childrenareawarded“goldstars”forgivingcorrectanswersorbeinggoodinclass.Thisalso

extendstotheworkplace,whereemployeesareawardedthetitle“employeeofthemonth”for

producinghighqualitywork.Nevertheless,theuseofrewardstomotivateandengageusersisan

oldtopicinhumancomputerinteraction.Gamesinspiredthecreationof“Heuristicsfordesigning

enjoyableandengaginginterfaces”intheearly1980s(Malone,1982;Deterding,Sicart,etal.,

2011).

Ingamification,itisassumedthatsocietyissimilartogames;bothcontainrules,prizesand

penalties,winningandlosing,competitionsandcollaborations,individualplayersandteams

Chapter2

10

(Wortley,2014).Someofthesefactorsareutilisedingamificationdesigntoinfluencebehaviour

andmotivateusers.

2.1.1 GameElementsandDynamics

Gameelementscanbeoneofthreetypes:mechanics,dynamics,andaesthetics.Thisisbasedon

thewell-knowngamedesignframeworkMDA,whichstandsformechanics,dynamics,and

aesthetics(Hunicke,LeBlancandZubek,2004).AccordingtotheMDAframework,game

mechanicsrefertotherules,rewardsandtheactionsthatthecanbecarriedoutbytheuserin

thegame.Inthegamificationliterature,gameelementsandgamemechanicsareusuallyusedas

synonymous(WerbachandHunter,2012;CodishandRavid,2014).Forexample,pointsand

badgesarereferredtoasgameelementsandgamemechanics.Ontheotherhand,game

dynamicsarewhatarisewithtimebecauseofgamemechanics(ZichermannandCunningham,

2011).Forexample,competitionarisesfromreceivingbadgesoradvancinginonaleaderboard.

Moreover,gameaestheticsaretheemotionsthatresultedfromtheexperienceofthegame.

Gamificationencompassesavarietyofelementsincludingsomeofthepopularvideogame

elementsthataregoal-orientedandfocusedonrewardingachievementssuchasbadges,levels,

leaderboardsandprogressbars.Therewardingsystemsusedingamificationcouldinvolvegaining

virtualcurrency,orredeeming,trading,giftingorexchangingpoints.Researchsuggeststhat

gamificationofactivitiescanleaveuserswithpositiveeffects(Hamari,KoivistoandSarsa,2014).

Thiscouldbeduetotheuseofrewards,whichbythemselvesleadtofeelingsoflikingand

pleasure(Schultz,2006).Gamificationcouldresultinasatisfyingfeelingwhenaccomplishing

regularoreverydaytasks.Itprovidestheuserwithascaleandmeasurementofhowtheyare

progressing(McGonigal,2011).Rewardscanbepresentedinmanyforms,includinggraphicsand

audio.Thisgivesfeedbacktousersandencouragesthemtodobetterandfinishchallenges.

Moreover,thereisanon-goingdebatebetweengamificationexpertsregardingthesoleuseof

rewardssuchaspoints,badges,andleaderboards(PBL)(Deterding,2012).Someclaimthatsimply

addingPBL,achievement,socialchallenges,andfeedbackleadstoanincreaseinuser

engagement(McCallum,2012b).However,Deterding(2010)arguesthatmerelyaddinggame

mechanicsandelementstoanactivityoraservicedoesnotresultinafunexperience.Heasserts

thatcreatingagamifiedexperienceisaniterativeprocessthatisbestdonewiththeinputof

gamedevelopers’expertiseandtestsonatargetaudience.Deterdingmaintainsthatmost

gamificationvendorsdonotusegamemechanicssuchasresourcemanagementandtime

pressure,butinsteadtheycreatenovel“gamy”formsoffeedback.This,however,doesnotcreate

long-termengagementbecausetheappealofnoveltywearsoffquickly(Deterding,2012).The

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11

location-basedappFoursquareisanexampleofthistypeofgamification.Theappgainedover25

millionusersduetotheuseofgamification(Frith,2013),however,afterafewmonthsthenovelty

effectworeoffanddidnotresultinsustainedandlongtermengagement(Carlson,2012).This

suggeststheimportanceofconsideringlong-termengagementandsustainabilitythroughintrinsic

motivation(seeSection2.2).

Gamificationisnotlimitedtotheuseofmechanicsordigitalcomponents(Deterding,Dixon,etal.,

2011).Itincludestheuseofothernon-mechanicalaspectsofgames,whicharegameaesthetics.

Storylinesandthemesaretwogameaestheticsthatcanbeusedingamification.Astorylineisthe

narrativeorstoryofthegame,whilethemesarethevisualbackgroundthatusersconnectwith.

Theseelementscouldcomeinconjunctionwiththeflowtheory(discussedinSection2.2.1.3)to

increasetheengagementofusersandenhancethegamificationexperience.Ingamification,the

storylinecouldbeusedtogivecontexttothegamifiedactivity,andthiscouldmakethe

experienceappearmeaningful.Forexample,intheself-managementofanillness,amonster

couldbeusedtorepresenttheillnessitself,whereuserscan“win”overthemonsterby

completingthetasksintheapp.Itcouldbethoughtofasameanstosustaintheengagementof

usersoverthelongterm.Thiscouldbehelpfulforgamificationinlearning(Kapp,2012).

Inhealthcare,thestorylinecouldbeincorporatedintheformofafictionalcharacterthattheuser

canbeatbymaintainingahealthydietforexample.Also,thefictionalcharactercouldbeamentor

thatguidestheuserandhelpthemadvancefromoneleveltotheother.Thestorylineelementin

agamificationapplicationcouldcreateanenvironmentthatisofrelevancetotheuser.

Turningbacktogamemechanics,anumberofthewidelyusedmechanicsingamificationare

suggestedtoberelatedtohumandesires.Bunchball(2012),compiledatabletoclarifythisidea

[Table2-1].Inthistable,itcanbeseenthatthedesiretoberewardedislinkedtogettingpoints

andstatusislinkedtolevelsingamemechanics.Alsowecanseethatstatus,achievements,and

competitionarelinkedtoallgamemechanics.Thetablesuggeststhatonecanusegame

mechanicsthatcorrespondstohumandesireinordertoinitiateorreinforcebehaviour.Thisis

commoninthevideogameindustryassuggestedbythetablecontent.

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Table2-1Similaritiesbetweengamemechanicsandhumandesires(Bunchball,2012)

HUMANDESIRES

GAME

MECHANICSReward

Status

Achievement

Self-Exp

ression

Competition

Altruism

POINTS u n n n n

LEVELS u n n

CHALLENGES n n u n n n

VIRTUALGOODS n n n u n

LEADERBOARDS n n u n

GIFTING&

CHARITY n n n u

Furthermore,Cugelman(2013)suggeststherearesevenprinciplesfromgamesthatcanbe

incorporatedintoappstomakethemengagingandfun.Heidentifiedtheseprinciplesafter

conductingareviewofanumberofgamificationstudiesfromacademicandnon-academic

sources.Table2-2liststheprinciplesthathereferstoaspersuasivestrategies.Accordingto

Cugelman,thesearewhatmakegamificationpersuasiveandengaging.Thus,itcouldmotivate

usersandinfluencetheirbehaviour(seeSection2.2.2).

Theidentifiedingredients,astheCugelmanpointsout,arerelatedtoprovenhealthbehaviour

changestrategies.However,thelastingredient“funandplayfulness”isanexceptionsinceithas

notbeenstudiedintensivelyinthehealthbehaviourchangeliterature.Gamificationaddsfunand

playfulnesstohealthbehaviouralchangetheoriesandcombiningthetwocouldresultinan

effectivechange.

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Table2-2PersuasiveStrategies(Cugelman,2013)

Thepersuasivearchitectureofgamificationandits7persuasivestrategiesGoalsetting Committingtoachieveagoal.

Capacitytoovercomechallenges Growth,learning,anddevelopment.

Providingfeedbackonperformance Receivingconstantfeedbackthroughtheexperience.

Reinforcement Gainingrewards,avoidingpunishment.Compareprogress Monitoringprogresswithselfandothers.Socialconnectivity Interactingwithotherpeople.Funandplayfulness Payingoutanalternativereality.

Examplesofgameelementsthatarewidelyusedingamificationincludepoints,badges,

challenges,leaderboards,levels,andvirtualgoods.AccordingtoBunchball(2012),game

mechanicsgeneratechallenging,fun,orsatisfyingemotionsassociatedwithgamifiedactivity,in

whichthegeneratedemotionsarethosewhichconstitutegamedynamics(suchasrewards,

achievement,competition,status,self-expression,andaltruism).

PBLandrewards,challenges,andlevelsareamongstthemostusedelementsfromgamesin

currentgamifiedapplications(Mekleretal.,2013;Hamari,KoivistoandSarsa,2014;Seabornand

Fels,2014;Dichevaetal.,2015;DarejehandSalim,2016).Cugelman(2013)compiledalistofthe

mostpopulargameelementsusedingamificationandthisisshownin[Table2-3].

Table2-3Tenmostpopulargamificationelements(Cugelman,2013)

Providingcleargoals Allocatingpoints

Offeringachallenge Showingprogress

Usinglevels(incrementalchallenges) Providingfeedback

Givingrewards Providingbadgesforachievements

Showingthegameleaders Givingastoryortheme

2.1.2 CulturalandSocialContext

Theriseofgamificationcouldresultfromtheintersectionofanumberoffactorsincludingthe

popularityofvideogames.RecentstudiesshowthatintheU.S.alone,consumersspent$23.5

billionongamesin2015(EntertainmentSoftwareAssociation,2016).Theincreaseinthesalesof

computerandvideogamescouldbeduetotheadvancesmadeintechnologyandinthegame

industryitself.Thewideacceptanceandavailabilityofsmartphonesandtabletscouldbeafactor

inbreakingthestereotypingofgamesandgamers.Additionally,36%ofthemostfrequentgamers

usesmartphonestoplaygames(EntertainmentSoftwareAssociation,2016).Thesedeviceshave

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14

notonlydiversifiedthegamesconsumerbase,butalsogivenafreshmeaningtosocialgames.

AccordingtoTheEntertainmentSoftwareAssociation,48%ofthemostfrequentgamersplay

socialgames.Theirstatisticsalsoshowedthatgamersarenolongerthoughttobeadolescent

males.Thestudyshowsthat59%oftheplayersaremaleand41%arefemale,breakinggender

stereotypesinthegameindustry.Moreover,thereisnoagelimittobeingagameplayer;infact,

thestudyshowedthattheaveragegameplayeris35yearsold,andthemostfrequentfemale

gameplayerisonaverage44yearsold.

Inlightofthis,thereisanincreasinginterestinthepotentialofgameelementstobeinfluentialin

otherfieldssuchashealthcare.McCallum(2012)suggeststhatthisis“thebeginningof

‘integratedgames’,wherethedataingamesandsocialnetworksbecomesintegratedwithall

otherformsofpersonaldata”.Theintegrationofgameelementsindifferentareasofourlivesis

unavoidable.Moreover,asmentionedearlier,millennialshavegrownupplayinggamesandare

technologicallysavvywithaccesstomanydigitalplatforms.Infact,theyareconnectedtotheir

digitaldeviceswhentheyworkandontheirleisuretime.Thissuggeststhatincorporatinggame

elementsineducationorhealthcarewouldappealtothem.

Littleresearchhasbeenundertakenonhowgenderdifferencesinfluenceandaffectgamification.

However,onestudyshowsthatfemalesaremorelikelytoperceivethesocialbenefitsofgamified

systemsthanmales(KoivistoandHamari,2014).Thestudyalsoreportedthatagedoesnotaffect

thebenefitsperceivedbygamification.Overall,itisimportanttokeepinmindthatnotallthe

aspectsofgamificationwillappealtoeveryone,suchascompetitions.Ingeneral,therearesome

studiesthatindicatethatmalesprefercompetitionmorethanfemales(CrosonandGneezy,

2009).Asthegamificationfieldisrelativelynew,toensurethatgamificationiswelldesignedand

implementeditneedstobestudiedintermsofthecommunityitistargeting.

2.1.3 GamificationandSeriousGames

Gamificationsharessomesimilaritieswithseriousgames,whicharefully-fledgedgamesdesigned

fornon-entertainmentpurposessuchaschangingtheplayers’knowledge,attitude,physicaland

cognitiveabilities,ormentalhealth(McCallum,2012a;Hochleitneretal.,2015).Bothgamification

andseriousgamesusefullgamestechniquesorelementsofgamesinareasoutside

entertainment.Table2-4showsthedifferencebetweenvideogames,seriousgames,and

gamification.

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Table2-4Differencesbetweenvideogames,seriousgamesandgamification

VideoGames SeriousGames Gamification

Designedas Acompletegame Acompletegame Notagame

Purpose Forpure

entertainment.

Foreducation,training,

assessments,andother

seriousscenarios.

Enhancemotivation,

engagement,and

influencebehaviour.

Seriousgamesareusedforeducationalortrainingpurposesinthehealthcarefieldandmany

otherareas,asopposedtovideogameswhicharesolelyusedforentertainmentpurposes

(Cawston,2012;Mccallum,2012).Unlikegamification,seriousgameshavebeenonthe

healthcaresceneforawhilenow(Susi,JohannessonandBacklund,2007;Mccallum,2012).In

particular,thereareseriousgamesdesignframeworksforrehabilitationtoincreasepatients

motivationandengagementwiththeirexerciseroutines(Floresetal.,2008;Barrettetal.,2016;

Holmesetal.,2016),andataxonomyforseriousgamesforrehabilitation(Rego,MoreiraandReis,

2002).Similarly,aframeworkforexergames,whichareseriousgamesthatutilisesensor

technologies,forhealthcare(Göbel,HardyandWendel,2010).Also,seriousgamesforindividuals

withAttentionDeficitHyperactivityDisorder(ADHD)tohelpthemdevelopbettertime

managementhabits(Frutos-Pascual,ZapirainandZorrilla,2014).Moreover,seriousgameshas

beenusedinhealthcareforeducationalpurposes(Tashiro,2009).Seriousgameshasalsobeen

usedforchildrenandadolescentswithdiabetestoeducatethemaboutdiabetesandhelpthem

fostergoodself-managementhabits(Wattersetal.,2006;Herteletal.,2013).However,itis

importanttomentionthatwhileseriousgamesandgamificationsharesomeelements(game

mechanics),theyareverydifferentfromeachother[Table2.4].Thus,itisnotappropriatetouse

seriousgamesframeworktocreategamificationapps.

Theentertainingaspectofseriousgamescouldplayaroleincreatinganengagingexperienceand

helpingusersinachievingtheseriouspurposeofthegame,suchaslearninganewskill.Ithas

beenpointedoutthatseriousgamestrytoinfluencepeopleinapositivewaypsychologically

sincethiscouldcontributeindevelopingnewskills,learningnewknowledge,andpromoting

positivehealthhabits(Wattersetal.,2006;Susi,JohannessonandBacklund,2007).

SeriousgamescanextendtophysicalactivitiesthroughtheusageoftoolssuchasMicrosoft’s

Kinect,whichisamotionsensordevicethatwasinitiallylaunchedin2010asapure

entertainmentadd-ontotheXbox360gamesconsole.However,inashorttimethedevicegained

popularityespeciallyincreatingseriousgamesforhealthcarepurposes,whichresultedina

significantincreaseinthenumberofhealthcareapplications(Cawston,2012).Jintronix,whichisa

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16

gamethathelpspatientsinphysicalandcognitiverehabilitation,isoneoftheexamplesofsuch

healthcareapplicationsthatgainedpopularitythroughKinect,aspointedoutinCawston(2012).

Sinceseriousgameshavebeenaroundforawhile,avarietyofseriousgamesapplicationsthat

aimtohelptype1diabeticpatientsimproveself-managementofdiabetesweredeveloped.One

oftheearlyexamplesistheNintendogamePacky&Marlon.Thisinteractivevideogame(Brown

etal.,1997)targetsdiabeticchildrenandteenstohelpthemimprovetheirself-managementof

diabetes.Diabeticdog1isanotherexampleofaseriousgamefordiabeticchildren.Thegame

takestheformofawidgetthatcanbeembeddedinwebsitesandblogs.Itteststheirknowledge

ondiabetesself-carebytakingcareofadiabeticdog.Thegamehasasocialaspectaswell;the

usercanchallengefriendswhoalsousethegame.

Asopposedtocreatingafull(serious)gametomanageanillness,gamificationisthedesignofa

gamifiedapproachforthispurpose.Whiletheemphasisofseriousgamesisthecreationofafull

game,theemphasisofgamificationistousegamedesignelementsandtechniquesinorderto

increasetheengagementofusers(ZichermannandCunningham,2011;KoivistoandHamari,

2014).

Chou(2014)referstogamificationasa“human-focuseddesign”,inwhichsystemsaredesigned

fortheusertosupporttheirneeds.Ontheotherhand,hestatesthatnon-gamificationdesigns

couldfocusonthefunctionalityofthesysteminsteadoftheuser(Chou,2014,2015).

2.1.4 GamificationApplicationFields

Gamificationhasbeengainingincreasedinterestinthepastfewyearsindifferentfieldssuchas

education,business,andhealthcare,tonamebutafew.Llagostera(2012)hascompiledalistof

referencesofgamificationtalks,books,andonlinediscussionstohighlighthowtheareaof

gamificationhasexpandedwidelyduringthepastyears.

Theexpansionofgamificationcouldbeattributedtothesuccessofapplicationslikethelocation-

basedserviceFoursquareandthesocialpartofthewell-knowngameFarmVille(Deterding,Dixon,

etal.,2011;ZichermannandCunningham,2011).InFoursquare2,differentbadgesandpointsare

awardedtousersforperformingcertaintaskssuchas“checkingin”atdifferentlocations.

However,eventhoughFoursquarewassuccessfulatthebeginning,wherethenumberof

registeredusersgrewfrom2millionto8millionin2011,theappdidnotsustainengagementof

1https://www.nobelprize.org/educational/medicine/insulin/game/insulin.html2https://foursquare.com/

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17

itsuserbase(Deterding,2010).Thiscouldbeduetothesoleuseofpointsandbadges.Users

stopped“checking-in”oncetheinitialnoveltyeffectworeoffwithtime.Thisisrelevanttothe

issueofmotivationingamification,whichwillbediscussedinSec.2.2.1.

2.1.4.1 AppsandSystems

Inthissectionweprovideexamplesofappsandsystemsfromdifferentfieldssuchaseducation,

citizenscience,andhealthcarethatutilisedgamification.Table2-5listedthe27appsandsystems

discussedinthissectionandclassifiedthembasedontheiraimintotencategorisei.e.children

healthcare,generalhealthmanagement,preventivecare,citizenscience,user-generatedcontent,

socialcauses,educationandtraining,exerciseandwell-being,marketingandbusiness,andself-

care.

Somenewswebsiteshaveutilisedgamificationtoincreasetheiruserengagement.Forexample,

theonlinenewsplatformMashable3rewardeduserswithbadgesforcommentingonandsharing

newsarticlesusingtheirsocialmediaaccountsandgainedfollowers.Tocustomizetheexperience

fortheiruserstheyusedspecialbadgesnamedafterwebmemes,whichwerefamiliartotheir

audience.

Gamificationisalsoimplementedinuser-generatedcontenttoencourageuserstoworktowarda

collectivegoal.OneexampleistheforumStackOverFlow4.Itcanalsobeusedincitizenscience

projectssuchasprojectsinbiology,physics,andchemistry.Foldit5,whichisauser-generated

contentpuzzle,isanexampleofabiochemistryprojectthatusesgamificationtoattractusersand

keepthemengaged(Fuchsetal.,2014).ResearchersattheUniversityofWashingtonhave

developedFoldit,inwhichusersaregivenscoresonfoldingthestructureofselectedproteins

usingthevarioustoolsprovidedtothem.Bydoingthis,userscanhelpincreatingquicksolutions

thatotherwisewouldtaketheresearchersyearstosolve.Infact,Folditresultedinacrowd-

sourceddiscoveryofthemysteryofhowakeyproteinmightaidthesearchforacureforHIV

(AndersonandRainie,2012).

Furthermore,gamificationhasbeenusedtopromotesocialcauses.Anexampleisthegamified

appRecyclebank6,inwhichgamificationisusedtoofferredeemablerewardsfortakingsmart

everydaychoicestoencouragebetterbehaviour.Usersoftheappareencouragedtoparticipate

inaseriesof“greenchallenges”whichteachthemaboutgreenlivingandhowtoliveamore

3http://mashable.com/2011/10/26/news-gamification/#z7TEl7V16kqj4https://stackoverflow.com/5https://fold.it/portal/6https://www.recyclebank.com/

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sustainablelife.InareportreleasedbyRecyclebankinpartnershipwithGoogleanalyticsandROI

research(King,2011),97%oftheparticipantsindicatedthattheirenvironmentalknowledge

increasedafterusingtheapp.Moreover,86%oftheparticipantsagreedthatthegamification

aspectoftheapphadpositiveeffectsontheirawarenessofthistopicandineducatingthem

aboutit.Thestudyalsosuggeststhatgameelementscanhelpinmotivatinguserstotakecertain

actionssuchaspositivesocialandenvironmentactions.

Educationisanotherareainwhichthereisagrowinginterestintheuseofgamification.Itisused

toencouragestudentsandengagetheminthelearningprocess.AccordingtodeSousaBorgeset

al.(2014),gamificationstudiesineducationfocusoninvestigatingtheuseofgamificationto

improvestudents’motivationsandskills,andmaximizetheirlearning.KhanAcademy7and

Codecademy8areexamplesofwebsitesandappswhereonlinecoursesareprovidedand

gamificationisused.Inbothexamples,usersarerewardedwithpointsandbadgesforcompleting

assignmentsandcontinuingthecourse.Anotherexampleofgamifiededucationwebsitesand

appsisRibbonHero9,whichwascreatedbyMicrosofttohelpuserslearnOffice.

Gamificationhasbeenimplementedinmanyaspectsofhealthcareincludingfitnessand

treatmentsofobesity,andintheself-managementofchronicillnesses(Muntean,2011;Blohm

andLeimeister,2013;BARGEN,ZientzandHaux,2014).Moreover,someofthemostsuccessful

examplesofgamificationapplicationsthatencouragehealthybehavioursareNike+10and

RunKeeper11(Kingetal.,2013).Bothusegamificationtoincreaseusers’motivationtoexercise,

andsupporttheminmonitoringtheirphysicalactivities.Toachievethis,usersarerewardedwith

virtualtrophiesandbadgesforundertakingphysicalactivities.Theyareabletovisualizetheir

progressandcompareittoothers.Allofthisisdoneinasocialcontextinwhichuserscan

competewithfamilyandfriendsandotherswithinthecommunity.Theycanalsosharetheir

achievementsandrewardswiththeirfriendsandfamilyinothersocialnetworks.Thus,thishelps

turnendurancesportsintogames(BlohmandLeimeister,2013).

AnothersuccessfulexampleofgamificationinhealthandwellnessisSuperBetter12,whichisatool

forself-improvementthatprovidesuserswithanengaging,andinteractiveexperimenttoassist

theminreachingtheirhealthgoals(SuperbetterLabs,2013;Roepkeetal.,2015).Theapplication

7https://www.khanacademy.org/8https://www.codecademy.com/9https://www.microsoft.com/en-gb/download/details.aspx?id=2653110http://nikeplus.nike.com/plus/11https://runkeeper.com/12https://www.superbetter.com/

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tracksofusers’“quests”andpresentsdailyandweeklyto-doliststoreachgoalsonestepata

time.Theappprovidesuserswithpersonalisedassistance,feedbackonperformance,andadvice.

Zamzee13isanotherexampleofanappdesignedtoincreasethemotivationofchildrenandyoung

adolescentsforphysicalactivities.Itisusedinconjunctionwithaspecificwearabledevicethat

measuresactivitiesandconvertsthemtoredeemablepointsforbothvirtualandreal-liferewards.

SimilartoNike+andRunkeeper,Zamzeeuserscanadvancetohigherlevelsbasedontheir

rewardsandaccomplishments.Moreover,theycancompetewithfriends.

PainSquad14isanotherexampleofagamificationapplicationinhealthcare.Theappisdesigned

tohelpchildrenfromtheageofeighttoeighteenyearsoldtotracktheircancerrelatedpainby

keepingdailyreports.Thereportsincludeinformationabouttheplaceofthepain,itsseverity,its

effectontheuser’sactivities,thecauseofthepain,andwhatmakesitbetterorworse.Usersare

providedwithvirtualrewardsforusingtheappandmaintainingthereports,andtheycan

advancetohigherlevelsastheycontinueloggingtheirdata.

CafeWell15isagamificationplatformtargetingorganizationworkplacestoencourageemployees

topartakeinonlinecompetitionsinagemlikeenvironmenttoimprovetheirlifestyle.Itusedtobe

namedKeasandfocusoncompetitions,raffles,andquizzes16.However,thenewandimproved

platformfocusesonsocial,gamingandpersonalizationtechniquestodrivehealthcarevalueand

changeindividualbehavioursintheorganization.UsersarerewardedforcompletingHRAand

biometricscreening,andforengagingwithrecommendedfitnessactivitiesandcommunities

basedontheirhealthcondition.

SlimKicker17isagamifiedappfortrackinghealthandfitness.Ithelpsusersstaymotivatedto

reachtheirdietorfitnessgoalsbyturningtheprocessofachievingthisintoagame-like

experiencetheycanwin.Usersareawardedpointsforeatinghealthy,exercising,andcompleting

challengesprovidedintheapp(e.g.quittingsodaforaweek).Theappisalsobasedona

communitywhereuserscanenterchallengeswithothersandshareaccomplishments.Moreover,

toretaintheinterestofusers,thedifficultyofchallengesincreasesgraduallyastheuser

progressestohigherlevels.Theappalsoprovidesuserswithpersonalizedadviceandreminders

fromavirtualcoach.

13https://www.zamzee.com/14http://www.sickkids.ca/Research/I-OUCH/Pain-Squad-App/index.html15https://welltok.com/16http://www.enterprise-gamification.com/mediawiki/index.php?title=Keas17http://www.slimkicker.com/

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MangoHealth18isagamificationappfortheself-managementofillnesses.Ithelpsusersmanage

theirmedication,adheretoit,andadopthealthyhabits.Usersareaskedtocreateascheduleof

healthyhabitsthattheywanttomaintain.Thesecouldincludetakingmedicationontime,

recordingweight,checkingbloodpressureandotheractivitiesrelatedtoone’shealth.Thenthe

appprovidesuserswithreminderstomeettheirscheduledgoals.Userscanrecordinformation

aboutthehealthyhabitstheywanttomaintain,suchashowtheirmedicationmadethemfeel,

andtheycansharethenotestheytookwiththeirdoctors.Theappenablesuserstocompare

theirstatisticswithotherusersoftheapp.Moreover,alongwithvirtualrewards,theappgives

usersachancetoenteraweeklyraffle.

Bant19isanexampleofagamifiedself-managementappfordiabetes.Thefirstversionoftheapp

targetedadolescentswithdiabetestohelpthemtrackbloodglucoseandprovidedthemwitha

community.UserswererewardedwithiTunesmusicandappstoencouragethemtotransform

theirbloodglucosetestresultstotheapp.ThepilotevaluationoftheappbyCafazzoetal.(2012)

showedthattheusers’dailyaveragefrequencyofbloodglucosemeasurementincreasedby50%.

Thestudyalsoshowedthatusersweresatisfiedwiththeappandwouldcontinuetouseit.The

appwasupdatedin2016wherenewfeatureswereaddedsuchastrackingdiabetes-related

informationotherthanbloodglucose,suchasdiet,weight,andphysicalactivities(Goyaletal.,

2016).Moreover,gamificationforself-managingdiabeteswillbediscussedinSec.2.3.2.

Lookingatalltheexamplesmentionedinthissection,thereisnoonecriteriaforcreatinga

gamificationexperienceforapps.However,itcanbenoticedthatthehealthcareapplications

discussedinthissectionshowsimilarapproachestogamification,specificallytheuseofPBLto

motivateusers,andtheincorporationofsocialaspects.Thisalignswiththeworkofthisthesis,

whichwillbementionedinsubsequentsections.

Applicationscanutilisegamificationforeithershorttermuseorlongtermuse.Forexample,

gamificationcanbeusedinasurveyapptoengagetheaudiencewiththeappforonetimeonly

(i.e.completingthesurvey),ortocollectdata(e.g.citizenscience)andoncethedataiscollected

theappisnolongertobeused.Ontheotherhand,someappsusegamificationengageusersfor

alongterm,suchasinhealthcareapplicationsandspecificallytheself-managementofchronic

illnesses(see2.3.3wherewediscusssystematicreviewsforself-managementapps).Clearly,

theseappscategoricallydifferfromeachotheranditisnotpossibletofollowthesamecriteria

(framework)toachievetheirpurposes.

18https://www.mangohealth.com/19http://www.bantapp.com/

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21

Table2-5showsotherthegamificationappsdiscussedandotherexamplescategorisedbasedon

theirpurpose.

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22

Table2-527Gamificationappsclassifiedinto10categories

Child

renHe

althcare

Gene

ralH

ealth

Man

agem

ent

Preven

tivecare

Citizen

Scien

ce

User-gen

erated

conten

t

SocialCau

ses

Educationan

dtraining

Exerciseand

wellbeing

Marketin

g/and

bu

siness

Self-care

Zamzee Keas SlimKicker Foldit StackoverFlow RcycleBank KhanAcademy Nike+ MyStarbucksReward

Bant

Painsquad

SuperBetter MangoHealth

Opower Codecademy RunKeeper FreshDesk MySugr

RibbonHero HealthMonth MangoHealth

Treehouse Foodzy MoviPill

CourseHero EveryMove Ayogo

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23

2.1.4.2 Providers

Thereareanumberofserviceprovidersthat“offeragamificationlayer”thatcanbeintegrated

intoapplicationsandwebsites.AmongtheseprovidersareBunchballandBadgeville,whichare

thetwomostknowncompaniesforgamification.Bothcompaniesarefocusingondriving

customerloyaltyandengagement,andemployeeproductivity.Bunchballcreatedthefirst

gamificationplatform,Nitro,whichisimplementedby300companiesincludingAdobeandHP

(Bunchball,2014).Badgville’sgamificationsolutionsarealsoimplementedbysomeofthelargest

companiesintheworldsuchasSamsung,AmericanExpressandOracle(Lynch,2013).Astudy

donebyGartnerin2011predictedthatmorethan50%ofcompaniesthatmanageinnovative

processeswilladoptgamification(Goasduff,2011)andthat70%ofGlobal2000organisationswill

haveatleastonegamifiedapplication(Pettey,2011).Theworld’slargestcompaniessuchasNike,

SAP,Pearson,Cisco,UnitedAirlines,Microsoft,Siemens,andIBMareusinggamification

(ZichermannandJoselin,2013).Gartner’sstatisticsalsoindicatedthatorganizationsthatused

gamificationexperiencedanincreaseof29%insiteactionsinashortperiodoftime.Thus,the

numberoforganizationthatutilizesgamificationisexpectedtorapidlyincreaseoverthenextfew

years.Moreover,arecentreportbyMarketsandMarkets20indicatedthatgamificaitonis

estimatedtobean11billiondollarindustryin2020.

2.1.5 GamificationFrameworks

Thereexistsomeframeworksthattrytohelpinincorporatinggamificationtootherfields.

However,theexistingframeworksaremostlybusinessoriginated(Moraetal.,2015).Noneofthe

frameworkslistedinthereviewarticlementiongamificationframeworksforhealthcare.Thisgap

willbethefocusoftheworkofthisthesis.

In2012,Marczewski21introducedagamificationframeworknamed“Andrzej’sGamification

Framework”.Thisframeworkconsistsoftwoparts.First,thereiseightstepsthatthedesigner

mustundertakebeforedevelopingthegamificationsystem,inwhichstep6and7areiterative.

Thesecondpartoftheframeworkconsistsofsevenpointsthatthedesignermustkeepinmind.

Part1

1. IknowwhatIamgoingtogamify.

20http://www.marketsandmarkets.com/PressReleases/gamification.asp21https://www.gamified.uk/2012/10/09/simple-gamification-framework/

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2. IknowwhyIamgamifyingit.

3. Iknowwhowillbeinvolved.

4. IknowhowIamgamifyingit.

5. Ihaveanalyticssetup.

6. Ihavetestedwithusers.

7. Ihaveactedonfeedback.

8. Ihavereleasedthesolution.

Part2:

• Thinklikeagamedesigner.

• Planforcheaters.

• Intrinsic>extrinsic.

• Don’tbeevil.

• Rememberthefun.

• Besocial.

In2017,Marczweski22proposedarevisedgamificationframeworkthatconsistsofthreemain

iterativesteps:

1. Definetheproblem,theusers,andsuccess.

2. Design/buildthesolution.Designingtheuserjourneyconsistof4steps:

a. Thebehaviour.

b. Themotivations.

c. Emotions.

d. Themechanics.

3. Refine.

AnotherframeworkfromindustryisOctalysisdevelopedbyChou(2014).Theframeworkhas

beenmostlyusedincompanies,andproductdesigntoincreaseuserengagement,and

motivation.Itisdividedintoeightcoredrives.Eachonerepresentshumanmotivationdrivers:

epicmeaningandcalling,developmentandaccomplishment,empowermentofcreativityand

feedback,ownershipandpossession,socialinfluenceandrelatedness,scarcityandimpatience,

unpredictabilityandcuriosity,lossandavoidance.Thesearedividedinto“leftbrain”coredrivers,

whichrepresentextrinsicmotivations,and“rightbrain”coredrivers,whichrepresentintrinsic

motivations(morewillbediscussedonintrinsicandextrinsicmotivationinSection2.2.1.1).

22https://www.gamified.uk/2017/04/06/revised-gamification-design-framework/

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Moreover,thereisanonlineOctalysistoolthatisavailabletomapgamifiedappsagainstthe

framework’seightcoredrives.Inarecentpaperthistoolwasusedtoclassifystressmanagement

appsthatusegamification(EwaisandAlluhaidan,2015).Thestudyshowsthat50%oftheappsin

thestudyuseextrinsicmotivations,and33%oftheappsinvolvedsocialelementsintheformof

sharingdatawithfriendsorinvitingfriendstotheapp.Moreover,thestudyindicatedthatonly

33%oftheappsusedintrinsicmotivations.Thisisalignedwithwhatisdiscussedinthe

gamificationliteratureaboutthefocusonextrinsicmotivators,whichcouldresultinan

unsustainableapp(discussedinSec.2.2.1).

Bothframeworksaretoogenericandcamefromtheindustryandbusinessside.Itmightbe

arguedthattherightapproachtogamifytheself-managementofchronicillnessesistostartfrom

theneedofthepeopleconcerned.Moreover,theirhealthcareproviders’opinionsshouldbe

takenintoaccountwhencreatingagamificationframeworkfortheirself-management.These

needsareunderstoodbythehealthcaregiversandtheindividualswithchronicillnesses.Asfaras

weareaware,thereisnosuchapproachintheliterature.Fillingthisgapmaywellbeimportantin

helpingthechronicillnesscommunitytobenefitfromgamification,whichisthefocusofthis

research.

Atthestageofwritingupthisthesis,ageneralmethodonhowtoapplygamificationwas

introducedbyMorschheuseretal.(2017).InaspecialsectionoftheComputerHumanBehaviour

Journal,theauthorspointoutthefactthatgamificationisreceivingmoreattentionfrom

academiaandbecominganacademicdisciplinethatmergesdifferentfieldsofresearch(Nacke

andDeterding,2017).

2.2 GamificationandHumanPsychology

Inadditiontotheengagementaspectsborrowedfromvideogames,gamificationisalso

influencedbypsychologyasitplaysamajorroleinexistinggamificationappsandframeworks

(Moraetal.,2015).AccordingtoZichermannandCunningham(2011),gamificationismore

psychologythantechnology.Gamificationcouldinfluencepeople’sbehaviour,whichmakesit

powerful(Hamari,KoivistoandSarsa,2014).Itisimportanttounderstandbehaviourandhowitis

createdinordertochangeorinfluenceit.Humanpsychologyplaysamajorroleingamification.

Somebehaviouralmodelsandtheoriesareapplicabletogamification(Kapp,2012)suchas

motivation(intrinsicandextrinsic),operantconditioning,self-determinationtheory,theFogg

behaviourmodel(FBM),andthenudgetheory.Thesewillbediscussedinthissection.

Peopleoftenneedtoberecognizedandobtaininstantpositivefeedback,andgamificationcan

usethistopromotechangeinbehaviourordriveuserengagement.Inadditiontosatisfyingthese

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needs,peoplecanbemotivatedindifferentwaysincludingachievingpersonalgoals,and

obtainingrewardsandincentives(Castro-Cedeno,2001).

2.2.1 Motivation

Motivationisoneofthemainconceptsingamification(Nicholson,2012).Itiswhatmakesgames

engaginganddriveshumanbehaviour.Thereareanumberoftheoriesthatexplainmotivation

andhowitaffectsbehaviour,suchasself-determinationtheoryandflowtheory,andthesewillbe

discussedinthissection.

2.2.1.1 IntrinsicandExtrinsicMotivation

Motivationisthedesiretodosomethingorperformanaction.Oneofthetheoriesthatareused

tounderstandmotivationistheSelf-DeterminationTheory(SDT)(RyanandDeci,2000).The

theorysuggeststhatpeopledothingsforeitherintrinsicorextrinsicreasons.Thus,therearetwo

typesofmotivation:intrinsicandextrinsic(illustratedinFigure2-2).

Inintrinsicmotivationthreearethreebasicpsychologicalneeds:

• Competence:beingeffectiveindealingwithone’ssurroundings.

• Relatedness:beingconnectedtoandpartofacommunity.

• Autonomy:havingfullcontrolofone’slife.

Extrinsicmotivationisdividedintofourtypes:

• Externalregulation:Themotivationthatiscausedbyexternalrewardsorduties,inwhicha

person’sbehaviourismotivatedbecauseofexternalreasonstoreachawantedoutcome.For

example,anacademicpublishingacertainnumberofpapersinaspecificamountoftimeto

beeligibleforapromotion.

• Introjectedregulation:Themotivationthatiscausedbyexternalreasonsbutself-imposedby

internalpressureorfeelingsofguilt,inwhichapersonismotivatedbyanexternalreasonbut

unlikeexternalregulation,thepersoninternalisesthereasonandself-imposesit.For

example,apersongoingtouniversitybecauseoftheirparents.Theybelievethattheywill

maketheirparentsproudorhappybyattendinguniversity.

• Identifiedregulation:Themotivationthatiscausedbyanexternalreason,thoughunlikethe

previoustypesmentioned,thepersonidentifiesinternallywiththeexternalmotivator

becauseitleadstoanoutcomethatisinternallyvaluabletothem.Thus,thebehaviouris

thoughttobeuseful.Forexample,followingadietbecauseitwillmakeapersonhealthier.

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Integratedregulation:Thistypeofmotivationissimilartointrinsicmotivation,inwhichaperson

isinternallymotivated.Thedifferenceisthatwhileintrinsicmotivationisinherentlyenjoyable,

integratedregulationarisesbecausethepersonbelievesthatthethingtheyaremotivatedtodois

importantfortheirimage.Forexample,doingsportbecauseitispartofaperson’simageofwho

theyare.

Figure2-2ExtrinsicMotivationClassification(adaptedfrom(RyanandDeci,2000))

Itisessentialtounderstandthedifferencebetweenthesetwotypesandhowtoapplythem

togetheringamification.Intrinsicmotivationistheinnatedesiretodothingsoutofenjoymentor

love(RyanandDeci,2000).Examplesofintrinsicmotivatorsareobtainingasenseofachievement,

feelingsofmastery,purpose,acceptance,orfulfillingcuriosity.Ontheotherhand,extrinsic

motivationisdoinganactivityinordertoreceivearewardandnotbecausethepersonis

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interestedintheactivityitself(RyanandDeci,2000).Examplesofextrinsicmotivationcouldbe

money,gainingstatus,gradesorcollectingpointsandbadges.

Itisnoticeablethatsomegamifiedapplicationsandservicesfocusonextrinsicmotivation(Sudan,

2013).Somegamificationappsuserewardsandincentivestomotivateuserstodocertaintasksor

increasetheirengagement.Whilerewards(extrinsicmotivators)couldhaveapositiveeffecton

people(Schultz,2006),iftheyareusedontheirownitmightnotleadtosustainablegamification.

Thisisduetothefactthatextrinsicmotivationcaneasilyloseitsappealwithtime(Hamari,

KoivistoandSarsa,2014).Ingamification,extrinsicmotivationcouldbeusedtojumpstartan

activity.Thenifthegamificationisdesignedcorrectlytheusercouldbeabletorealisetheintrinsic

valueoftheactivityandwoulddoitwithouttherewardsorextrinsicmotivations.

Understandingthedifferencebetweenextrinsicandintrinsicmotivationisessentialindesigning

gamifiedapplicationsandservices.Moreover,identifyingwhatintrinsicallymotivatesthetarget

audienceofthegamifiedinterventionisimportant.Forexample,therewouldbeadifference

betweentheintrinsicmotivatorsofanaudiencewhowanttolearnaboutatopicandthe

audiencewhowanttoself-manageachronicillness.Whengamifyinglongtermactivitiessuchas

healthcare(e.g.self-managingchronicillnesses),itisessentialtoincludebothintrinsicand

extrinsicmotivatorsandnotuseextrinsicmotivatorssolely(Mccallum,2012).Ingamification,the

threeintrinsicmotivatorscouldbeusedtohelpenhancetheintrinsicmotivationoftheuser,

whichcouldleadtosustainableengagement.

2.2.1.2 OperantConditioning

Oneoftheconceptsrelatedtomotivationisoperantconditioning,whichisatermcoinedbythe

AmericanpsychologistandbehaviouristSkinner(1938)inhisbookTheBehaviourofOrganisms.In

thebook,operantconditioningisdefinedastheprocessinwhichbehaviourischangedand

modifiedusingreinforcement.AccordingtoSkinner,reinforcementcomesintwoforms:positive

andnegative.Ontheonehand,positivereinforcementsarerewardsthataregiventothe

individualafterthedesiredbehaviour.Forexample,receivingabonusatworkforincreasingsales.

Ontheotherhand,negativereinforcementsaretheremovalofanundesiredorunpleasant

outcomeafterthedesiredbehaviourisperformed.Thus,behaviourisstrengthenedassomething

negativeisremoved.Inuniversities,forexample,increasingtheteachinghoursforsomelecturers

canbeconsideredanegativereinforcement.Inparticular,iftheydonotmeettheexpectationof

theirsuperiorsintermsofthenumberofproducedpublicationsperyear.Anexampleofpositive

reinforcementwouldbetogivelecturersmonetaryrewardeverytimetheypublishapaperina

highqualityjournal.

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Whenappliedtogamification,positivereinforcementcouldbedevelopedthroughtheuseof

rewards.Desiredbehaviourcouldberewardedbypointsandbadgesinwhichtheactionthat

leadstoreceivingthemisthestimuliinvolved.

2.2.1.3 TheFlowTheory

Atheorythathasbeenusedinvariousfieldsincludinggamestoenhancepeople’sengagementis

flowtheory.ThepsychologistCsikszentmihalyi(1997)defineditasamentalstateofabsorption

andengagementinanactivity.Intheflowstate,theuserisintrinsicallymotivatedandcompletely

immersedinwhattheyaredoing.Thus,timeandthephysicalworldaroundtheuserbecomes

irrelevant.Csikszentmihalyialsodefinedeightelementsoftheflowstate:challenge-skillsbalance,

action-awarenessmerging,cleargoals,unambiguousfeedback,concentrationonthetaskathand,

senseofcontrol,lossofself-consciousness,transformationoftime,andautotelicexperience.

Someoftheseelementsaremoresuitableforvideogames(i.e.action-awarenessmerging,lossof

self-consciousness,transformationoftime,andautotelicexperience),whileotherslikechallenge-

skillsbalance,cleargoals,feedback,andsenseofcontrolcouldbesuitableforgamificationin

healthcare.

Engagingvideogamescanleaduserstotheflowstate.However,thegameactivitiesshouldbe

designedaccordingtotheusers’skilllevel.Thiscanbeaccomplishedbystartingagamewithan

easylevelandgraduallyincreasingthedifficultyastheusermovesfromoneleveltothenext(as

theirskillsincrease)(Cugelman,2013),whichcanhelpinsustainingtheflowstate.Ontheother

hand,ifthegamefailstoachievethechallenge-skillbalance,theuserwilleitherbeboredifgame

istoosimpleorquitifthegameistoodifficult(Figure2-3).

Ingamification,flowtheorycouldbeusedtosustaintheusers’interestinperformingthetasks.

Forexample,whengamificationisappliedtotheself-managementofdiabetes(discussedinSec.

2.3.2),thechallenge-skillbalancecouldbeachievediftheappasksanewusertoentertheir

bloodglucosetesttwiceadayonlyasafirststage.Then,iftheusermanagedtodothatfora

weekforexample,theappwillaskthemtoentertheirtestresultsatleastthreetimesadayasa

secondstage.Inthisscenario,otherflowelementssuchasprovidingtheuserwithcleargoalsto

achieve,instantfeedbackontheirperformance,andprovidingthemwithasenseofcontrolcould

beutilisedaswell.

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Figure2-3TheFlowTheory:Challenge–SkillBalance(Adaptedfrom(Csikszentmihalyi,1990))

2.2.1.4 Maslow’sHierarchyofNeeds

TheHierarchyofNeedsbyAbrahamMaslowisoneofthemostwell-knowntheoriesthat

attemptstoexplainhumanmotivation(Maslow,1943).Inhiswork,Maslowfocusesonintrinsic

motivationsandsuggeststhattherearefivelevelsofhumanneeds.Eachlevelmustbefulfilledin

orderforpeopletodesiretheneedsofthenextlevel.Startingfromthebottomofthepyramidin

Figure2-4,thefirsttwolevelsshowthemostbasichumanneedsthatincludeeating,drinking,

havingawarmplacetolivein,andfeelingsecureandsafe,whichinturnarephysiologicalneeds.

Thenexttwolevelsarepsychologicalneeds,whichincludetheneedforbelongingandbeing

loved,andtheneedforself-respect,prestigeandfeelingsofaccomplishments.Accordingto

Maslow,afterfulfillingalltheseneeds,peoplestartneedingself-actualisation.

Whenthinkingaboutgamification,thebelongingandesteemneedscouldbeofinterest.

Belongingcoverstheneedtobepartofacommunityandtohavesocialcohesion.Accordingto

ZichermannandCunningham(2011),mostpeoplearesocializersandthusmanygameshave

utilisedthesocialfeature.Inagamificationappforhealthcare,forexample,itmightbeeffective

tobasesomeofthegamificationaspectsaroundacommunity.Moreover,esteem,whichisthe

needforself-esteem,achievements,competence,andtheneedforrecognitionandrespectfrom

others,couldalsobepartofagamificationapp.Theseneedscouldbefulfilledinthecontextof

theapp.Forexample,inthegamificationofanexerciseappwheretheusergoalistobemore

activeandloseweight,theesteemneedsofMaslow’smodelcouldbefulfilledbyillustratingthe

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achievementsoftheuser,andthiscouldleaveuserswithpositivefeelingsaboutthemselves

(increasingtheirself-esteem).

Figure2-4Maslow'sHierarchyofHumanNeeds

2.2.1.5 Pink’sElementtoDriveMotivation

AccordingtoPink(2009),intrinsicmotivationisdrivenbythreeelements:autonomy,mastery,

andpurpose.First,autonomyiswhenpeoplehavefullcontroloverwhenandtowhatlevelthey

wanttocarryoutanactivity.Ingames,oneofthecomponentsofautonomyisenteringtheFlow

State(definedinSec.2.2.1.3).Second,masteryisbecomingbetteratacertainactivity.For

example,ingamesthesenseofmasterycanbereachedthroughimprovementinplayingand

progressingtowardsgoals(McGonigal,2011).Finally,purposeiswherepeoplehaveareasonto

doanactivity.

2.2.2 BehaviourChange

Behaviourchangeistheprocessinwhichanundesiredbehaviourisabandonedinfavourofa

betterone.Therearesomemethodsandtheoriestoassistinchangingthebehaviourofan

individualoracommunity(N.I.C.E,2007).Theyareusedinmanyfields,especiallyintheareaof

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healthcare.Furthermore,ithasbeenproventhatonlinebehaviourchangemethodsaresuccessful

ininfluencingusersbehaviour(Cugelman,ThelwallandDawes,2011).

2.2.2.1 FoggBehaviouralModel(FBM)

B.J.Fogg(2009)proposedamodelthatexplainshowbehaviouroccurs.TheFoggBehaviour

Model(FBM)showsthathumanbehaviourisanoutcomeofthreeelements.Thefirstelementis

motivation,whichiswhenthepersonhasthedesiretoperformcertainbehaviour.Thesecond

elementisability,whichiswhenthepersonhasthecapacitytoperformthebehaviour.Thelast

elementistrigger,whichiswhenthepersonistriggeredtoperformthebehaviourthrough

differentcues.Moreover,Foggstatesthattheseelementsmusthappenatthesametimeinorder

forbehaviourtoresult(Figure2-5).

Figure2-5Fogg'sBehaviourModel23

Furthermore,influencingbehaviourrequirescreatinganewbehaviourandeliminatingan

undesiredhabit.Thereareanumberofsituationswherepeoplechoosetochangetheir

behaviour.Forexample,somepeopleareinternallymotivatedtobecomehealthiersothey

workoutandeathealthyfoodontheirown.Otherwaystochangebehaviourcomesfroma

changeinenvironment,ordevelopinganewbehaviourthroughasequenceofsteps.Thelatteris

called“tinyhabits”amethodusedtochangingbehaviourinwhichaplannedsequenceofsmall

changesindailyroutineresultsintheadoptionoftinyhabitstoreachadesiredbehaviour(Fogg,

2011,2013).Itreliesonthefactthatsmallchangesareeasiertoacceptthanbigshiftsindaily

23http://www.behaviormodel.org

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behaviour(Figure2-6).Creatingsmallhabitsstep-by-stepcouldensurethattheylastlongerthan

byjustexploitingmotivationallyextrinsicrewards.

Figure2-6Tinyhabits

2.2.2.2 TheNudgeTheory

Nudgetheorycomesfrombehaviouralscienceandisusedtodrivebehaviour.Ithasbeenapplied

inpoliticalandeconomicenvironments(ThalerandSunstien,2009).Itconcernspositive

reinforcementandindirectsignalstowardanon-forcedactionbycreatingthesimplestpathto

thebehaviour.Forexample,usingdefaultswhereusersaregivenadefaultchoiceoutofmany

choices.Thispushestheusertochoosethedefaultchoicethinkingitistherecommendedone

(Wu,2014).Theuseofthenudgetheorycouldcreateagoodenvironmentwheregamificationis

usedbygivingrewardsandincentivesaswellas‘nudging’behaviourintowantedbehaviours.

AccordingtoWu(2014),thenudgetheorycanbeusedingamificationtodrivebehaviourthrough

simplifyingthecontexttoleadtothedesiredbehaviour.

2.3 GamificationforHealthcare

Theuseofgamificationinhealthcarecouldaddfunandplayfulness.Gamificationcouldresultin

aneffectivechangeinbehaviourwhencombinedwithhealthbehaviouralchangetheories.

Furthermore,influencingbehaviourinhealthcaresituationsisnotaneasytask.Accordingto

Cugelman(2013),digitalhealthcareapplicationsandservicesimpactonly10%oftheirusers.In

general,toinfluenceuser’sbehaviour,onemustunderstandhowbehaviouroccursandwhatare

thefactorsthatcontributetoit,asdiscussedintheprevioussection.

Thehealthcareindustryisexperiencingsignificantchangesduetoadvancesininformationand

communicationtechnologies(Eysenbach,2008).Theseadvanceshaveledtochangesin

communicationbetweenpatientsanddoctors,andbetweenpatientsthemselves.Healthand

medicalinformationhasbecomemoreavailableandeasytoaccess.Also,therehavebeen

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advancesinpublichealtheducation,practices,andself-management.Amoreuser-centred

approachisbeingusedtofacilitatechangeinhealthdelivery.Therehasbeenafocusonutilizing

mobiletechnologiesforhealthbehaviourinterventions.Smartphonesarebecomingatoolthat

offersuserstheabilitytoadheretomedication,manageillnesses,andmonitortheirhealth

wherevertheyare(SizemoreandJones,2011).Thereisagrowinginterestinhealthmonitoring

andtrackingtechnologies(Swan,2009),andtherecenthealthappsandhealthtrackingplatforms

createdbysmartphonescompaniessuchasAppleandSamsungareanindicationofthat(Morris,

2014).Moreover,onlinecommunitiesprovidepatientswiththeemotionalandpsychological

supporttheymightneed.Todaythereareagrowingnumberofsupportgroupsandself-

managementtoolsontheInternet(Hughes,JoshiandWareham,2008;VanDeBeltetal.,2010).

However,someWebandmobilehealthcareinterventionsmightbeconsideredtobelacking

effectiveandengagingfeatures,whichmaymakethemunattractivetousers.

McCallum(2012)claimedthatgameswillbeintegratedwithhealthcareinterventions,andit

couldbeanessentialpartofit.Theresearcherarguesthatthedesireforasenseofcontrolover

one’shealth,andthefocusonpersonalizedhealthcarehasleadtoanincreaseingameand

gamificationintegrationtohealthcare.Insupportofthis,StottandNeustaedter(2013)pointed

outthatsuccessfulgamedynamicsindeedincreasethefeelingsofcontrolinusers.Moreover,

gamificationcouldbeveryusefulinhealthcareinterventions.Notonlybecauseitisengagingand

motivating,butalsobecauseofthesimilaritiesbetweengameelementsandpersonalized

healthcareinthattheybothfocusontheuserandtheirabilities.Inaddition,theresearcherstates

thattheuseofFlowtheoryingamesandgamificationresemblessomecharacteristicof

personalizedhealthcare,inwhichtheinterventionmatchestheuser’sabilityandthedifficulty

increaseswiththedevelopmentoftheuser’sability.

Indeed,theadoptionofgamificationhasbeengrowingindifferentfieldsincludinghealthcare

(Hamari,KoivistoandSarsa,2014).Inhealthcare,gamificationhasbeenreceivingagreatdealof

attentioninbothacademicresearchandtheindustry(Brownetal.,1997;AndersonandRainie,

2012;Mccallum,2012;Aholaetal.,2013;Cugelman,2013;SeabornandFels,2014;Wortley,

2014;Lister,West,Cannon,SaxandBordegard,2014;Miller,CafazzoandSeto,2014;deVetteet

al.,2015;KamelBoulosetal.,2015;Lazemetal.,2015).Theattentiongiventogamificationmight

beattributedtotheperceivedusefulnessandpotentialbenefitsofgamification,especiallywhen

dealingwithchronicillnessesanddailyself-managementbypatients(Lister,West,Cannon,Sax

andBordegard,2014;Allametal.,2015a;Johnsonetal.,2016).Chronicillnessesrequire

repetitivebutimportanttasksthatcouldbemadeeasiertohandlewithgamification(discussedin

Sec.2.3).

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Gamificationwithitspotentialbehaviouralchangecapabilitiesandtheelementofenjoymentit

bringsisapplicabletopersonalhealthcare.Therewardingelementsingamificationmayhelpin

motivatinguserstowardshealthybehaviours,whichtheymightfinddifficulttostartormaintain.

Theseincludediseasepreventionbehavioursanddiseasemanagement.Furthermore,Werbach

andHunter(2012)maintainsthatgamificationisfundamentallyamotivationaltool.Inhealthcare,

gamificationcanbeusedtoincreaseusers’commitmenttocertainhealthbehaviours,or

encourageuserstoexercisemoreandtakemedicationregularly.Itcouldhelpinintegrating

healthyhabitsandmakethemadailyroutine.Thiscouldbethereasonbehindthenoticeable

increaseinthenumberofappsthatarededicatedtogamifyinghealthcare.

Somehealthcareactivitiesmightbedifficultortediouswhichcoulddiscouragepeoplefrom

undertakingtheseactivities.Forexample,exercising,makinghealthierchoices,adheringto

medication,anddiseasemanagement.Gamificationcouldturntheseactivitiesintoan

entertainingandrewardingexperience(Kingetal.,2013).Thisisbecausegamificationemphasizes

positivereinforcement,whichisthoughttobemoreeffectivethanpunishment.However,

rewardingusersforgoodbehaviourisnotanelementofgamificationinsomeapps.Forexample,

onegamificationapp“Stickk24”,whichismeanttohelpusersinquittingthehabitofsmoking,asks

formoneypaymenteverytimeausersmokesasapunishment.However,theapplicationhas

failed,andthisnegativereinforcementmighthavebeenthereason.

2.3.1 ChronicIllnessesandSelf-management

Oneoftheareasofhealthcareisself-managementofchronicillnesses.Therearemanychronic

illnessessuchasasthma,heartdiseases,diabetesandmanymore.Diabetesisaverycommon

chronicillnessandisthefocusofthisthesis.Itisametabolicdisorderthatresultsfromvarious

conditions.Therearetwokindsofdiabetes:type1andtype2.Theformerrequiresregular

injectionsofinsulin,whilethelatterdoesnotrequiresuchaction(AlbertiandZimmet,1998).The

autoimmunedestructionofaspecifickindofcellscalledbetacellsisthoughttobethecauseof

type1diabetes,andisthereasonbehindthelackofnaturallyproducedinsulininthebody(Yoon

andJun,2005;Association,2013).Type2diabetesisassociatedwithsomeinsulindeficiencyin

thebody(Association,2013).Thesymptomsofdiabetesincludelargeproductionofurine,

excessivethirst,lossofweight,andblurredvision(AlbertiandZimmet,1998).Moreover,theself-

managementofbothtypesofdiabetesisgenerallysimilarandincludesmonitoringbloodglucose,

foodintake,exercise,andtakingmedication(Phillips,2016).

24http://www.techhive.com/article/259717/

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Diabetesisconsideredtobethediseaseofthiscentury(Engelgauetal.,2003).Therearemore

than382millionpeoplearoundtheworldwholivewithdiabetes.Giventhisnumberandthehigh

prevalence,ithasbeencalledan“epidemic”bysome(Zimmet,AlbertiandShaw,2001;Bassett,

2005).TheMiddleEastandNorthAfrica(MENA)regionhas35milliondiabeticcases(Aguireeet

al.,2013).Forexample,thenumberofindividualswithdiabetesinSaudiArabiaisonetherise,

andhasrecentlyestimatedtobe64000individuals(Al-HerbishandEl-Mouzan,2008;Aguireeet

al.,2013).Moreover,theprevalenceofdiabetesamongyoungergenerationsintheMENAregion

isoneofthehighestintheworld(Aguireeetal.,2013).Thissuggeststheimportanceofcreating

effectiveself-managementinterventionsespeciallyfortheyoungerpopulation.

Infact,diabetesisaseriousdiseasethatcouldleadtootherillnessessuchasheartdiseases,

failureofthekidney,lossofsights,amputations,anddepression(Egede,ZhengandSimpson,

2002;Association,2013).Therefore,itisvitalforindividualswithdiabetestoproperlyself-

managetheirconditionandadheretotheirmedication.Thisrequiresagreatdealofself-care,

suchastakingmedication,keepingtrackoffoodintake,exercising,recordingthelevelofglucose

inthebloodonadailybasisandundertakingacertaintypeofdiet.

Clearly,theillnessrequiresself-managementskillsthatarevitalinpreventingthecomplications

associatedwiththediseaseandmaintainingahealthylife(TheDiabetesControland

ComplicationsTrialResearchGroup,1993).Thisincludestheabilitytodealwithdiabetes

requirementssuchaslifestylechanges,medication,andphysicalandsocialconsequences

(NodhturftandSchneider,2000;Dunning,2014).Thisallowspatientstomonitortheircondition

andmaketherequiredcognitive,behaviouralandemotionalchangestomaintainahealthylife

(ColemanandNewton,2005).Moreover,effectiveself-managementofdiabetesleadsto

reductioninhospitalizations,andemergencyvisits.Inaddition,diabetesstudiesshowedthat

effectiveself-managementimprovesglycaemiccontrol.

Individualswithdiabetesarerecommendedtoundertakeanumberoftasksandshare

informationabouttheirconditionandactivitieswiththeirdoctors.Thesetasksincludekeepinga

recordofglucoselevelsintheirblood,andalogofphysicalactivities(Heisleretal.,2002).Such

taskscanbemadeeasiertoperformbyusingelectronicapps(e.g.GlucoseBuddy25,Glooko

Logbook26,andAgaMatrixDiabetesManager27).Performingthepreviouslymentionedtasksand

25http://www.glucosebuddy.com/26https://www.glooko.com/27http://agamatrix.com/products/agamatrix-diabetes-manager/

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reportingthemenablesindividualswithdiabetestoreceivefeedback,andthushelpsthemto

accomplishtheirgoalsofbeinghealthy(Raoetal.,2010).

Moreover,electroniclogbookscouldallowindividualswithdiabetestoobserveanyalarming

conditionssuchasspikesintheirbloodglucoseafterspecificmeals.Anotherbenefitofsuchapps

istheeaseofsharingmedicalinformationwiththeirdoctors.Infact,studieshaveshownthatthe

useofsuchservicesonsmartphonesishelpingimmenselyinreducingreadmissionstohospitals

andtheprogressionofdiseases(Buie,SizemoreandJones,2012;Morris,2014).Moreover,itis

importanttoempowerindividualswithdiabetestobeabletotakecontroloftheirconditionand

liveahealthylife.Animportantwaytoachievethatistomotivatethemtoadoptahealthierstyle

ofself-management(Kharrazi,FaiolaandDefazio,2009).

Anotherimportantsideofself-managingdiabetesistherolethatpeer-supportplays.Thereare

differentwaysforreceivingthissupportsuchasbeingpartofasupportgroupeitherphysicallyor

online.ThelatterhasgainedmomentumwiththeadventoftheInternet(White,2001).Both

typeshavebeensuggestedtohavepositiveeffectsonindividualswithdiabetesandotherchronic

illnesses(Davison,PennebakerandDickerson,2000).Onlinepeersupportcouldbemore

convenientformanyreasonsincludinganonymity,notbeingrestrictedbylocationortime,and

notrequiringspendingmoneyorefforttogotohospitalsorlocationsofmeetings.Findingother

individualswithdiabetesonlineinordertoreceivepeersupporthasbeenfacilitatedbysocial

networks(BoydandEllison,2007;Kleeketal.,2013).Infact,Zrebiec(2005)foundthatalmosthalf

oftheparticipants(inhisstudyonaFacebookcommunityfordiabetes)changedtheirviewon

theirillnessasaresultofbecomingpartofacommunity.

Therearemanybenefitsthatsocialnetworkingcanprovideforindividualswithdiabetes.These

includeemotionalandpsychologicalsupport(Zrebiec,2005;Heisleretal.,2007),learningfrom

theexperiencesofother(vanderVen,2003),askingquestionswithoutfearingfromjudgment

(White,2001),andthepositiveeffectthattheyleaveontheirhealth(Seeman,1996;Barreraet

al.,2002).Thesefeaturesareparticularlyimportanttoindividualswithdiabetesashasbeen

suggestedbymanystudies(Egede,ZhengandSimpson,2002;vanderVen,2003;Peyrotetal.,

2005;Zrebiec,2005).

2.3.2 GamifyingSelf-managementofChronicIllnesses

Itissuggestedthatgamificationcouldpositivelyinfluencepatientswithchronicillnessesinterms

ofadheringtotheirmedicationandself-manageeffectively(Cafazzoetal.,2012;Mccallum,

2012).Gamifyingthiscouldturnthetediousandrepetitivetasksofself-managinganillnesstoa

rewardingandmoreengagingactivity(Kingetal.,2013).Moreover,itcanleadtoanincreasein

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theadoptionofdigitalhealthcareservices,whichisgenerallyslow,oftenbecausesuchservices

arepoorlydesignedanddonotmeetusersneeds(BiesdorfandNiedermann,2014).El-Gayaret

al.(2013)suggestthattheusers’expectationsandhealthcareproviders’insightshouldbe

consideredinthedesignofself-managementapps.Moreover,inarecentstudy,75%of

participantsshowedinterestinusingdigitalhealthservices,especiallyiftheyprovideassistance

withroutinehealthtasks(BiesdorfandNiedermann,2014).However,thesolerelianceonpoints

andbadgescoulddamagethelongevityeffectofgamificationandthusdiminishthepurposeof

gamificationinthefirstplace.Whilepointsandbadgesareapartofgamification,thereareother

crucialgametechniquesthatneedtobeconsidered.Therefore,tobenefitfromalltheadvantages

ofgamification,oneneedstounderstandtheenvironmenttowhichitisapplied,sospecific

gamificationtechniquescanbetailoredandappliedtothisspecificenvironment.

Havingachronicillnessrequiresagreatdealofself-care.Patients’timeisdrainedbythemany

repetitivetasksthatarerequiredbytheirphysicians.Theseinclude,takingmedication,keepinga

noteoftheirfoodintake,theirexercisesandother.Mobileappscanprovideassistanceinthis

department,allowingpatientstobemoreefficientintheirself-management(Gruman,2013).As

McGonigal(2011)statedinherbookRealityisBroken,

“Themorewestarttomonitorandself-reportourdailyactivity…themorewewillbe

abletochartourprogress,setgoals,acceptchallenges,andsupporteachother…”

Gamifiedservices,withtheirabilitytoengageandmotivateusers,havehighpotentialin

healthcare(Primacketal.,2012).Theycouldenhancetheeffectivenessofself-managementand

adherencetomedication.Moreover,themotivationtotakemedicationatacertaintimeand

takingcareofone’shealthisintrinsic.Peoplewanttobehealthy,andwhentheyfeelsicktheywill

takeactiontogetbetter.However,whendealingwithself-managementofchronicillnessesitis

importanttorealizethosepatientshavetocopewiththeillnesseseverydayoftheirlives.The

motivationtodosocoulddiminishwiththeotherstressoflifeortheycouldbecomeboredofthe

routinetasks.Theideaofincorporatinggamificationtothetasksofself-managingtheillnessisto

engageusers,motivatethem,andutilizethesocialaspectingamificationtocreatebehaviour

changeinafunandplayfulway.Itcouldalsominimizeanynegativeconnotationsthatcouldbe

associatedwiththechronicillness.Moreover,itcouldbeimportanttoconveytotheuserthe

benefitstheycangainfromusingthegamificationhealthapp.Forexample,explaintotheusers

thatgamificationcouldhelpthemprovideamoreenjoyableexperienceinmanagingtheir

condition.

Asdiscussedearlier(seeSec.2.2)gamificationcanbethoughtofasamotivationaltool(Werbach

andHunter,2012).Generally,thereisanumberofwaystomotivatepeopleinordertoachieve

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theirgoals,satisfypersonalneeds,fulfilleaderexpectations,andgainrewardsorincentives

(Krippendorff,2004).Thehealthcarecommunityhasbeenrealizingthepowerofgamificationon

motivation(AndersonandRainie,2012;Cugelman,2013;Allametal.,2015b;deVetteetal.,

2015).Thus,somegamificationfeatureshavebeenincorporatedinanumberofhealthandfitness

apps(Kingetal.,2013;Lister,West,Cannon,SaxandBordegard,2014).

Gamificationhasbeenalsoincorporatedinsomeself-managementappsfordiabeticpatients.A

studybyCafazzoetal.(2012)pointedoutthatgamifieddiabetesappsshowedanimprovementin

patients’self-monitoringabilities.Anexampleofagamifiedself-managementappfordiabetesis

MySugr28,whichhasfeaturessuchasmonitoringthelevelofglucoseintheblood,calories,and

medication.Theapplicationusedpositivereinforcementintheformofrewardsforbeing

consistentinperformingtheself-managementtasks.Atthetimeofconductingthisresearchthe

appwaslimitedbygeographicallocation,asitisavailableonlytousersintheUnitedStatesand

Europe.However,asof2017theappisspreadingtomorecountries.

MonsterManor29isanotherexampleofagamifieddiabetesmanagementapplication.Ithelps

familiesofyoungchildrenwithType1diabetesloggingtestresults.Theappaimstoengage

childreninmanagingtheirhealthandimprovingtheiradherencetotreatmentwhilehavingfun.

Furthermore,MonsterManorisintegratedwithBlueLoop30,whichisadiabetes-trackingapp.This

allowschildrentoentertheirdiabetesinformationandparentstomonitortheirchildren’shealth.

Childrenareawardedeverytimetheyentertheirtestresults,andtheycancollectmore

“monsters”and“gold”thatcanbeusedtobuynewpetsfortheirmonsters.Theappistargeting

childrenbutitalsoallowsparentstosupporttheirchildren’smanagementeffortsthroughinsights

andstrategiesprovidedbytheapp.

Thesearecommercialappsanddevelopedovertheyearstoreachapositionwheremany

featuresthattheresearcherobservedintheliteratureareincluded.Clearly,thisdevelopment

mightnothavebeenbasedonanextensiveresearch.Thoseappscouldhavefoundthebest

featurestoincludebytrialanderror,suggestionbyuser,orothermeans.However,giventhe

natureofthefieldtheresearcheraimedatfiguringouttheessentialaspectsthatshouldbe

includedinanappthatshouldbeincludedinanthattargetbasedonthethreeareasofliterature

reviewdiscussedinthischapter.Thesefeatureswillbesynthesisedinaframeworkwhichistoour

28http://mysugr.com29http://ayogo.com/blog/monster-manor/30https://blueloop.mycareconnect.com

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knowledgethefirstframeworkthattargetthegamificationoftheself-managementofchronic

illnesses.

Itcanbenoticedthatmanygamificationapplicationsinhealthcaredonotfollowstandardized

guidelines(SeabornandFels,2014).Itisarguedthatnotfollowinganystandardguidelinesmight

affecttheoverallexperienceoftheusers.Forinstance,userscouldgetboredofusingacertain

gamifiedapplicationifitonlyreliesonpoints,badges,andleaderboards(Farzanetal.,2008).

Also,somestudiessuggestthatgenderandagecouldbeafactorinhowsustainabletheusageof

gamificationis,particularlythatasageincreasesgamificationbecomeslessefficient(Koivistoand

Hamari,2014).Inhealthcareapplications,especiallytheonesthattargetself-managementof

chronicillnesses,developersareadvisedtotakeintoconsiderationallofthepreviousaspectsof

thatarerelatedtogamificationanditsapplicationinself-management.

Furthermore,therehasbeenrelativelylittleresearchontheuseofgamificationinself-

managementandadherencetomedication.Theacademicliteratureongamificationfor

healthcarelacksempiricaldataontheeffectsofgamificationinterventionontheself-

managementofchronicillnesses,whichcouldbeduetothedifficultiessecuringlongterm

fundingthatmightnotbeavailable(Mccallum,2012).

Thesocialelementsofgameshavebeenpartofthediscussionofgamificationandareperceived

tobeanessentialpartofit(Simões,RedondoandVilas,2012;HamariandKoivisto,2013).In

general,socialnetworkusersarekeenonsocialgaming(Simões,RedondoandVilas,2012),which

latelyhasbeenreceivingincreasedattentionfromgamers(EntertainmentSoftwareAssociation,

2016).Moreover,whendiscussinggamificationforchronicillnesses(specificallydiabetes)itis

importanttoconsiderthepositiveinfluencethatbeinginacommunityhaveontheuser(Hamari

andKoivisto,2013).Also,thereareuserswhoaremotivatedbythesocialinteractionandsharing

(Simões,RedondoandVilas,2012).

Thesocialaspecthasbeenestablishedasanimportantfactorforindividualswithdiabetes,and

thatitcanhelptheminmanagingtheirillness.Thus,asocialelementshouldbepartofany

gamifiedappforself-managementofchronicillnesses.Creatingacommunitythatencompasses

othergamificationaspectscouldprovideuserswiththepeersupporttheymightneed.Moreover,

thesocialaspectcouldenhancethegamificationexperiencebycreatingacontexttothegame

elementused(suchasfriendlycompetitions),andaddvaluetoothers(suchaspoints,badges,

andlevels).Itcouldalsoenhancethesustainabilityofthegamificationapp.

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2.3.3 TheGapintheLiteratureanditsImportance:

Theliteratureonself-managementappsfordiabetessuggeststhatthereisaneedforincreasing

theengagementofusersandprovidingbetterexperiencesforthem.Infact,arecentsystematic

reviewof14studiesontheeffectofappsinimprovingtheglycaemiccontrol(HbA1c)intheself-

managementofdiabetes,foundthattheeffectoftheappsdecreaseovertime(Houetal,2016).

Thisisduetothelackof:easeofuse,perceivedadditionalbenefits,andtheutilisationof

gamification(Houetal,2016;Scheibleetal.,2015).Theauthorsrecommendedthatfuture

applicationsshouldconsidertheuseofbehaviouralchangetheoriesandgamificationtoimprove

theself-managementprocessandtheHbA1c.

Furthermore,asystematicreviewby(Brzanetal.,2016)testedandevaluated65appfortheself-

managementofdiabetes.Intheirstudy,theyfoundthatonly3outofthe65appsprovideduseful

featuresfortheself-managementofdiabetes.Additionally,theyproposedanumberof

recommendationfordevelopersthatinvolvestheinputofmedicalexperts,includingsocial

supportelements,enablingbasicself-managementtasks(i.e.monitoringbloodglucose,

medication,nutrition,andactivitylevels),enablingsavingandsharingdata,includingmotivational

elementsforhealthbehaviourchange,andenablingalertsandreminders.

Ithasbeensuggestedthatincorporatinggamificationelementsintoappsfortheself-

managementofdiabetescouldenhancetheexperienceofusersandmotivatethemtocontinue

usingtheapp(Scheibleetal.,2015).Yet,averylimitednumberofappsfordiabetesself-

managementutilizegamificationelements(DiabetesMarket,2014).Theexistinggamifiedapps

donotreflectthegamificationapproachesfoundintheliterature(SeabornandFels,2014).In

theirpaper,SeabornandFels(2014)arguethattheoreticalworkisnotstudiedempiricallyand

thattheappsandsystemsthatappliedsomeofthetheoriesdidnottesttheirvalidityempirically.

Additionally,thecurrentimplementationsofgamificationinhealthcaredonotfollowacertain

criteria(framework)orstandardguidelines(Lister,West,Cannon,SaxandBordegard,2014).

Asdiscussedearlier(seesec.2.1.5),thereexistafewgamificationframeworks,however,mostof

themoriginatedintheindustryandtargettheuseofgamificationforbusinesses(Moraetal.,

2015).Theseframeworksarenotsuitableforpurposerelatedtoself-managementofchronic

illnessessincethisareadealswithpatientsandtheirdailymanagementroutines.Asfaraswe

knowtherearenogamificationframeworksordeveloperguidelinesfortheself-managementof

chronicillnesses.Thisgapwillbethefocusofthisthesis.

Inthisthesisweaimtoinvestigatetherichliteratureontheself-managementofdiabetes,

gamificationtechniques,andbehaviourchangetheoriesandsynthesisethekeyelementsneeded

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forthegamificationofself-managementofdiabetes.Giventhatthegamificationofself-

managementofchronicillnessesisstillconsideredtobeatanearlystageaframeworkandaset

ofcomprehensivedeveloperguidelinesareimportanttofillinthegapintheliterature.

Finally,itisessentialtoinvolvepeoplewithmedical,psychological,gamificationexpertise,and

theenduser(individualswithchronicillnesses)inthevalidationoftheframework.Oncethe

frameworkiscreatedandvalidatedasetofguidelinesfordeveloperswillbecreated.Thisisan

importantstepsinceinthisareadevelopers,softwareengineersarenotexpectedtoknowallof

theissuessurroundingtheareaofhealthcareandself-managementofchronicillnesses.The

guidelinesshouldenablethecreationofapplicationfortheself-managementofchronicillnesses

thatfollowsthethemesoftheframework.Theguidelinesmustreflectthevalidatedthemesof

theframework,anditshouldbeclearandpresentedatalevelthatcanbeusedbydevelopers.To

achievethis,itisimportanttoinvolveexpertsintheareasofsoftwareengineering,games,

gamification,softwaresustainability,healthcareapps,andapplicationdevelopment.

2.4 Summary

Inthischapteraliteraturereviewwasconductedonthethreemainareasofresearchinthis

theses.Thesearegamification,thepsychologyofgamificationincludingmotivationaland

behaviouralchangemethods,andself-managementofchronicillnesses,focusingondiabetes.

Theterm“gamification”,whichistheuseofgameelementsinenvironmentsotherthanpure

entertainment,wascoinedin2002/2003andgainedtheinterestofacademicin2011.Many

factorscontributedtotheriseofgamification,includingthepopularityofvideogamesespecially

amongstthosewhogrowupplayingthem,thewidespreaduseofsmartphonesandtracking

technologies,andthefocusonindividualandbehaviouralanalytics.Gamificationcanbeusedin

appsforlearningandeducation,marketingandbusiness,andhealthcaretoincreaseengagement,

enhancemotivation,andinfluencethebehaviourofusers.Itincorporatesgameelementssuchas

badges,levels,leaderboardsandprogressbars,whichareamongstthemostusedgameelements

ingamification,withmotivationalandbehaviourchangetheoriestoachievethis.

Gamificationisinfluencedbypsychologyandusesmotivationandbehaviouralmethodsin

combinationwithelementsborrowedfromvideogames.Thesetheoriesandmethodsplaya

majorroleinexistinggamificationappsandframeworks.Bothtypesofmotivation:intrinsicand

extrinsicareutilisedingamification.Intrinsicmotivation,whichistheinternaldesiretodothings

outofenjoymentorlove,isexemplifiedintheuseoftheself-determinationtheorythatliststhree

intrinsicmotivators:competence,relatednessandautonomy.Moreover,Pinkarguesthat

motivationisintrinsicanditisdrivenbythreeelements:autonomy,mastery,andpurpose.Onthe

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otherhand,extrinsicmotivation,whichisdoingthingssolelyfortheoutcome,isexemplifiedin

theuseofexternalrewardssuchaspointsandbadges.Theuseofbothtypesofmotivationscould

driveusers’motivationandinfluencetheirbehaviour.

Moreover,itisimportanttounderstandhowbehaviouroccursandwhatmotivatesittochangeor

influenceitthroughgamification.Thereareanumberoftheoriesandmethodsthatexplain

behaviourandhowitoccurssuchasFoggBehaviourModel,whichsuggestthatbehaviourisan

outcomeofthreeelements:Motivation,Ability,andTrigger.Accordingtothemodelthethree

elementsmusthappensimultaneouslyforbehaviourtooccur.Foggalsosuggestedtheuseof

“TinyHabits”methods,inwhichanactivityisbrokenintoasequenceofsmallchangesindaily

routineresultsintheadoptionoftinyhabitstoreachadesiredbehaviour.Furthermore,the

Nudgetheory,whichisthepositivereinforcementandindirectsignalstowardanon-forced

action,canbeusedincombinationwithgamificationtoencourageadesiredbehaviour.

Gamificationhasbeenappliedtodifferentfieldsincludinghealthcare.Oneoftheareasof

healthcarethatcouldbenefitfromgamificationistheself-managementofchronicillnesses.Living

withachronicillnesssuchasdiabetesrequiresagreatdealofcarefromtheindividual’sside.Self-

managingdiabetesincludesdailymanagementofmedication,keepingatrackoffoodintakeand

exercises,andmaintainingarecordoftestresults.Thisisvitaltopreventthecomplications

associatedwiththeillnessandtomaintainahealthylife.Gamificationcouldhelpinthisareaby

motivatinguserstowardshealthybehavioursthattheymightfinddifficulttostartormaintain.

Moreover,gamificationcouldhavepositiveimpactsonusersbyturningthetediousandrepetitive

tasksofmanagingdiabetestoamorerewardingandengagingactivity.Furthermore,

incorporatinggamificationwithanonlinecommunitytoprovideuserswithemotionaland

psychologicalsupportthattheymightneed.

However,eventhoughtherearesomegamificationframeworkstohelpinunderstandingitand

implementingit,theyaremostlybusinessoriginated.Asfarasweknowtherearenogamification

frameworksorguidelinesforhealthcareandespeciallyforself-managingchronicillnesses.This

gapwillbethefocusoftheworkofthisthesis.

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Chapter3: Methodology

Inthepreviouschapteraliteraturereviewofresearchontheareasofgamification,self-managing

chronicillnesses,andageneraloverviewofbehaviourchangemethodswasprovided.

Gamificationwasdefinedandasummaryofthecurrentstateofgamifiedapplicationswas

provided.Gamificationforhealthcarewasalsoexaminedandasummaryofseriousgamesinthis

particularsectorwasgiven.Theself-managementofchronicillnesses,focusingondiabetes,and

itsself-managementtoolsandcommunitieswascoveredtogetherwithageneralviewof

motivationandbehaviourchangemethods.

Inthischapter,anoverviewofresearchmethodsisgivenwheremixedmethods,andmulti

methodsarediscussed.Theresearchdesignandresearchquestionsaregiven.Moreover,the

researchmethodschosentoanswertheresearchquestionsareprovided.

3.1 OverviewofResearchMethods

Researchmethodsarethetechnicalproceduresfollowedwheninvestigatingaresearchproblem

oransweringaresearchquestion(Creswell,2003).Thereareanumberofdifferentmethodsthat

helptheresearchercollectdatafromparticipants.Thesearequalitativemethods,quantitative

methods.

Moreover,combiningquantitativeandqualitativemethodsiscalledmixedmethodresearch.This

typeofresearchwidelyusedinthesocialsciences(Creswell,2003;Morse,2003).Thetwo

methodschosencanbeconductedinparallelorsequentially(JohnsonandOnwuegbuzie,2004).

Thecombinationofqualitativeandquantitativemethodsisthoughttoprovideabroaderimage

andabetterunderstandingoftheissueinquestion(Creswell,2003).

Ontheotherhand,theuseoftwoormorequalitativedatacollectionmethodsinaresearchstudy

iscalledmulti-methodresearch(Morse,2003).Thistypeofaresearchstrategydoesnothaveto

mixquantitativeandqualitativeresearchmethods.Usingtwoqualitativedatacollectionmethods

provideawiderperspectivetoanswertheresearchquestion(Morse,2003).Thishelpswith

obtainingresultsfromdifferentangles,providingtriangulation.Thisprovidesmore

comprehensiveresultsthaneitherstudyon-its-own(Morse,2003).

Combiningmethodseitherinamixedmethodapproachormulti-methodapproachfallsunderthe

conceptoftriangulation(Rothbauer,2008).Triangulationistheuseoftwoormore

methodologiestoimprovetheaccuracyofthefindings(Denzin,1978;Jick,1979).Theuseof

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mixedmethodscreatesabalancebetweentheweaknessesofqualitativeandquantitative

methods(Jick,1979).Thisallowsforawell-roundedrepresentation(Thurmond,2001).Thereare

fourtypesoftriangulation(Denzin,1978;Thurmond,2001;Guion,DiehlandMcdonald,2002;

RunesonandHöst,2009):

• Datatriangulation:anumberofdifferentsourcesisusedtocollectdata.Thisincludes,

differentpeople,atdifferentlocations,andatdifferenttimes.

• Investigatortriangulation:dataiscollectedusingthesamemethodsbutbydifferent

researchers(investigators)

• Theoreticaltriangulation:thesamedatainterpretedbydifferentexpertsfromdifferentfields

ofstudy.

• Methodologicaltriangulation:datacollectedusingmultiplequalitativeand/orquantitative

methodstovalidatethesamething.Thisincludesusinginterviewsandquestionnairesor

focusgroupsandindividualinterviews.

3.1.1.1 QualitativeMethods

Qualitativeresearchmethodscompriseavarietyofmethodsthatareusedinmanydisciplinesof

academicresearchincludingsocialsciencesandnaturalsciences.Thistypeofresearchhelpsin

understandingthehumanfactorsoftheresearchproblem,specifically,thepopulationthatis

involvedinit(Mack,WoodsongandMacQueen,2005).Qualitativeresearchmethodsenablethe

researchertouncoverthesocial,gender,ethnicity,andreligionrolesintheresearchproblem

(Crotty,1998).Thus,itreliesmoreonopen-endedquestionsthatallowparticipantstodiveinto

theissue(Crotty,1998).Thedatacollectedfromqualitativeresearchingeneraltaketheformof

notes,audiorecordingsortranscripts(Mack,WoodsongandMacQueen,2005).

Oneofthequalitativemethodsthatiswidelyusedisinterviews.Byusingthismethod,the

researchercanexploretheresearchquestioninmoredepthanddeduceimportantinformation,

suchasopinions,feedback,critique,andconfirmationsthatonlythosewhohavetheknowledge

orexpertisecanprovide.Interviewscanbeconductedeitherindividuallyorinagroup,whichis

alsoknownasfocusgroupdiscussions(KruegerandCasey,2009).

Individualinterviewscanbeconductedinaface-to-facemanner,byphone,orthroughvarious

digitalinterfaces(Rogers,SharpandPreece,2011).Therearefourtypesofinterviewsthatdepend

onthetype,sequenceandwordingofthequestionsasked.Theseare,structuredinterviews,

semi-structuredinterviews,unstructuredinterviews,andfocusgroups(Britten,1995;Rogers,

SharpandPreece,2011).Thesemi-structuredinterviewischaracterisedbyanumberofclose-

endedquestions,andopen-endedquestions.Inthistypeofinterviewparticipantsaregiventhe

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spacetoelaborateontheissueathand.Thus,creatingaconversationbetweeninterviewerand

interviewee(Britten,1995).Theinterviewercouldstartwithanopen-endedquestionthatleads

tootherquestionsbasedontheparticipant’sanswer(Britten,1995).

Onthehand,focusgroupsallowtheresearchertocollectthedatafrommultipleindividualsatthe

sametime,andthroughasemi-structuredinterviewprocess.Itisaneffectivetechniquefor

exploringattitudes,inform,testideas,programs,andproducts(Kitzinger,1995;Logie,2014).

Oneoftheadvantagesoffocusgroupsinterviewsisthatitinvolvesselectingparticipantsbased

onasharedaspectrelevanttothestudy.Anotheradvantageistheabilitytocollectdatafroma

numberofpeopleatthesametime.Thediscussionbetweenparticipantsisconsideredtobeone

ofthemainstrengthsofthefocusgroupmethod,becausethisiswhatenrichesthedatacollected

byencouragingsharingandcomparingofexperiencesandopinionsbetweenparticipants

(Morgan,1997;Logie,2014).Ingeneral,participantsshouldbeencouragedtodiscussandshare

experiencesandpointsofview(Kitzinger,1995;Logie,2014).Infocusgroupinterviewsthe

sessionscouldtakeoneortwohours.Thus,itisrecommendedthattheinterviewsareaudio

recordedandnotesaretakenduringthesessions(Kitzinger,1995).

Usingthismethod,theresearcheroragroupleaderhastomoderatetheinterviewsession.The

extenttowhichtheresearcherisinvolvedinaskingquestionsandmanagingthegroupdiscussion

variesdependingonthegoalofthestudy.

Thesamplingandnumberofparticipantsinthefocusgroupdiffersbasedontheresearch

questionandgoal.Theidealsizeofthegroupmayrangefromfourtoeightindividuals,andthe

idealnumberoffocusgroupsessionsisthree(Kitzinger,1995;Logie,2014).However,groups

couldbesmallerorlargerthanthat(Morgan,1997).

Overall,usingthesedifferenttypesofinterviewscanbebeneficialintermsofhavingflexibility

withthequestionsasked,theabilitytoexplainanymisunderstandings,andcollectingany

additionalinformationfromparticipantswhenneeded(Britten,1995;DiCicco-Bloomand

Crabtree,2006).Ontheotherhand,somedisadvantagesofusinginterviewscouldbethatit

requiresmoretimethanquestionnaires,forinstance,andthelackofanonymity(Openakker,

2006).Thesefactorscoulddiscourageparticipantstobepartofthestudyorleadtobiased

answers.However,thesedisadvantagescouldbeeliminatedbytheresearcherthroughmaking

theparticipantascomfortableaspossiblebytakingtheirschedule,preferredwayof

communicationintoconsideration(Berg,2009).

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3.1.1.2 QuantitativeMethods

Quantitativeresearchmethodistheuseofstatisticaltechniquestoinvestigatethedatacollected

byansweringquestionswithpre-determinedlistofanswers.Usingthismethod,researchersseek

toconfirmacertainhypothesisthroughhighlystructuredmethodssuchasquestionnaires,

surveys,andexperiments(Mack,WoodsongandMacQueen,2005).Quantitativemethodssuchas

questionnairescanbeusedtocollectopinionsofalargesampleofparticipantsaswellastheir

demographicaldata(Rogers,SharpandPreece,2011).Thedatacollectedthroughthismethodare

mainlynumericalinform.

Thequestionnairetypeofquantitativeresearchmethodisaverycommonchoiceforthe

collectionofdata.Thisisbecausethecollectionofthelargenumberofdatacanbecarriedout

cheaply.Moreover,thedatacollectedisconvenienttoanalyseobjectivelythroughstatistical

analysisthanqualitativedata(e.g.interviews).Otheradvantagesincludeeliminatinganybiases

thatcanresultinaone-on-oneinterview,andretaininganonymity(SomekhandLewin,2005).On

theotherhand,thelackofcontactbetweentheresearcherandtheparticipantwhenanswering

thequestionnairemeanstheanswersareacceptedeveniftheparticipantmisunderstoodor

chosethewronganswerbymistake.Thus,thequestionnairemustcontainstraightforward

questionsthataresimpletocomprehendbyparticipants.Moreover,thelackofcontroloverwho

fillsoutthequestionnaireisalsoconsideredadisadvantage(SomekhandLewin,2005).Therefore,

muchcaremustbeputindistributingthequestionnairetoitsintendedaudience.

Inquantitativeresearch,thesizeofthesampleshouldbedeterminedbeforeconductingthe

study.Thesizeofthesampleplaysaroleinthestatisticalvalidityoftheconclusionsdrawnfrom

analysingthedata.Therequiredsamplesizedependsonthetypeofthestatisticaltestbeing

used.Theminimumsizecanbecalculatedbasedonanumberofstatisticalvariables.

Therearemanypackagesthatareavailabletocarryoutthiscalculation.Apopularchoiceisthe

programG*Power,whichisastatisticalpoweranalysistool(Fauletal.,2007,2009).Itcomputes

therequiredsamplesizegiventhreevariables:

• Type1error(alpha),whichrepresentafalsepositiveresult.

• Type2error(beta),whichrepresentafalsenegativeresult.

• Effectsize,whichdeterminesthemagnitudeofthedifferencebetweentwogroups.

Sampleareusuallychosentorepresentalargerapopulation(Mendenhall,BeaverandBeaver,

2012).Oneofthemethodstocollectasample,whichisconsideredanon-probabilitysampling,is

snowball(Chromy,2008).Thismethodreliesonselectingparticipantsfromthetargeted

population,thenaskingthemtofindotherparticipantsfromthesamepopulation.Oneofthe

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advantagesofthismethodisthatitallowstheresearchertofindparticipantsfromspecific

populationsthatmightbeunder-representedordifficulttoreach.However,oneofthedrawbacks

ofthismethodisthatitcanrequirealongtimeuntiltherequiredsamplesizeisachieved.

Table2-5summarisethedifferencesbetweenthequalitativeandquantitativemethods.Thetable

showsthedifferenceintermsofpurpose,datacollectionapproach,sample,datatype,

advantages,anddisadvantages

Table3-1DifferencesbetweenQuantitativeandQualitativeMethods

QuantitativeMethodology QualitativeMethodology

Purpose Measurequantities,andtesta

hypothesis

Acquiringin-depthinsights,confirmation,

andassessment

DataCollection

Approach

Questionnaires,andexperiments Interviews,andfocusgroupdiscussions

Sample Largenumberofparticipants Smallnumberofparticipants

DataType Numerical Textualoraudio

Analysis Statisticalanalysis Interpretativeanalysis

Advantages Abilitytocompare,andgeneralize.

Obtainingviewsandexperiencesthat

otherwisehardtoacquire.

Disadvantages Thelackofabilitytoclarifyorask

participantstoelaborate

Lackofanonymity,andtimeconsuming.

3.2 ResearchProcess

Therearetwomajoraimsofthisresearch.First,toprovideavalidatedframeworkforthe

gamificationofself-managementofchronicillnesses.Thisaimiscapturedinthefollowing

researchquestion:

RQ1:Whatisanappropriateframeworkforthegamificationofself-managementof

chronicillnesses?

Second,totransformthevalidatedframeworkintoasetofguidelinesfordevelopers.Thatenable

themtoimplementgamificationintheself-managementofchronicillnesses.Thisaimiscaptured

inthefollowingresearchquestion:

RQ2:Whatisanappropriatesetofclear,useful,andimplementabledeveloper

guidelinesforthegamificationofself-managementofchronicillnesses?

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50

Inordertoachievethesegoals,byansweringtheresearchquestions,theresearchwasdivided

intothreephasesasillustratedin(Figure3-1).

Thefirstphaseconsistedofaliteraturereview,theidentificationoftheresearchgap,and

proposingaframework.Thepurposeoftheliteraturereviewwastogatherinformationon:

1. Gamificationanditsapplications

2. Thepsychologyofgamificationandthetheoriesofbehaviourchangethatareusedinthis

area.

3. Chronicillnessesespeciallydiabetesanditsself-managementrequirements.

4. Theuseofgamificationinhealthcare.

Next,theresearcherwasabletoidentifythegapintheliterature,whichwasmanifestedinthe

lackofavalidatedframeworkintheareaofgamificationintheself-managementofchronic

illnessesespeciallydiabetes.Then,theresearcheridentifiedtheconceptsthatarenecessaryfor

combininggamificationinthisspecificareaofhealthcare,andsynthesisedthemintoone

constructthatistheproposedframework.Theoutcomeofthisphasewaspublishedin

(AlMarshedietal.2017)and(AlMarshedi,Wills,andRanchhod2015).

Thesecondphasewastovalidatetheproposedframeworkbyusingamixed-methodapproach.

Thequalitativemethodconsistedofexpertinterviews.Theinterviewswereconductedwith

expertsfrommedicalfields,includingendocrinologists,diabeticeducators,psychiatristsand

psychologists,andexpertsfromacademiaingamificationandseriousgames.Theaimofthe

interviewswastovalidatethecontentoftheframework.Ontheotherhand,thequantitative

methodconsistedofaquestionnairetocollectdatathatmeasurestheattitudesofindividualwith

diabeteswhoarebasedinSaudiArabiatowardstheframework.Theoutcomeofthisphasehas

beenpublishedin(AlMarshedi,Wills,andRanchhod2016).

Thethirdandfinalphaseincludedtwoparts.First,buildingasetofguidelinesfordevelopers

basedonthevalidatedframework.Next,validatingthecontentoftheguidelinesusinga

qualitativemulti-methodapproach.Namely,expertinterviewsandfocusgroupinterviews.The

expertinterviewsareconductedwithexpertsingamedesign,userexperience,seriousgamesfor

healthandgamification.Afteranalysingthefindingsfromtheexpertinterviewsandupdatingthe

guidelinesaccordingly,thesecondqualitativestudytookplace,whereanumberofdevelopers

andsoftwaresustainabilityexpertswereinterviewedinsmallfocusgroupsessions.Thepurpose

ofthefocusgroupinterviewswastoreviewanddiscusstheupdatedguidelinesfromthe

perspectiveofdevelopersasameantocross-validateit.Theoutcomeofthisphasewaspublished

in(Almarshedi,Willsetal.2017).

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51

Figure3-1ResearchProcess

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52

3.3 Summary

Inthischapter,anoverviewofresearchmethodsisgivenwheremixedmethods,andmulti

methodsarediscussed.Theresearchdesignandresearchquestionsweregiven.Moreover,the

researchmethodschosentoanswertheresearchquestionswereprovided.

Researchmethodsaretheproceduresusedtoexplorearesearchproblemortoanswera

researchquestion.Therearetwowaystocollectdata:qualitativeresearchmethods,and

quantitativeresearchmethods.Thecombinationofquantitativeandqualitativemethodsiscalled

mixed-methodresearch.Ontheotherhand,theuseoftwoqualitativemethodsiscalledmulti-

methodresearch.Moreover,combiningtworesearchmethodsisthoughttoprovidebetter

understanding,andawiderperspectivetoanswertheresearchquestion.

Qualitativeresearchmethodshelpinunderstandingthehumanfactoroftheresearchproblem.

Interviews,bothindividualandgroupinterviewsarepopularqualitativeresearchmethods.Onthe

otherhand,quantitativeresearchmethodistheuseofstatisticaltechniquestoinvestigatethe

datacollectedbyansweringquestionswithpre-determinedlistofanswers.Thismethodisusedto

confirmacertainhypothesisthroughhighlystructuredmethodssuchasquestionnaires,surveys,

andexperiments.

Thisthesishastwomajoraimsofthisresearch.First,toprovideavalidatedframeworkforthe

gamificationofself-managementofchronicillnesses,whichiscapturedRQ1.Second,to

transformthevalidatedframeworkintoasetofguidelinesfordevelopersthatenablethemto

implementgamificationintheself-managementofchronicillnesses,whichiscapturedinRQ2.

RQ1:Whatisanappropriateframeworkforthegamificationofself-managementof

chronicillnesses?

Toanswerthisquestion,theresearcherconductedaliteraturereviewongamificationandits

applications,thepsychologyofgamificationandthetheoriesofbehaviourchangethatareusedin

thisarea,andtheself-managementofchronicillnessesespeciallydiabetes.Then,theresearcher

identifiedthegapintheliterature,whichisthelackofavalidatedframeworkintheareaof

gamificationintheself-managementofchronicillnessesespeciallydiabetes.Afterthat,the

researcheridentifiedanumberofelementsfromtheliteratureandsynthesisedthemintoone

constructthatistheproposedframework.

Theframeworkwasthenvalidatedusingamixed-methodapproach:expertinterviews,and

questionnaires.Theinterviewswereconductedwithexpertsfrommedicalfields,including

doctorsofdiabetes,diabeticeducators,psychiatristsandpsychologists,andexpertsfrom

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53

academiaingamificationandseriousgames.Thequestionnairesweredistributedtocollectdata

thatmeasurestheattitudesofindividualwithdiabeteswhoarebasedinSaudiArabiatowardsthe

framework.

RQ2:Whatisanappropriatesetofclear,useful,andimplementabledeveloper

guidelinesforthegamificationofself-managementofchronicillnesses?

ToanswerRQ2,asetofguidelinesfordeveloperswasdesignedbasedonthevalidated

framework.Then,thecontentoftheguidelineswasvalidatedusingaqualitativemulti-method

approach:expertinterviews,andfocusgroupinterviews.Forthefirststudy,expertsingame

design,userexperience,seriousgamesforhealthandgamificationwereinterviewedindividually.

Then,thequalitativedataoftheinterviewswasanalysedtheguidelineswereupdatedbasedon

thefindings.Afterthat,thefocusgroupinterviewswereconductedwithanumberofdevelopers

toreviewanddiscusstheupdatedguidelinesfromtheperspectiveofdevelopers.

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55

Chapter4: FrameworkanditsValidation

Theliteraturereviewchapter(Ch.2)presentedaninvestigationonthethreemainareasoffocus

inthisthesis:gamification,behaviourchange,andself-managementofchronicillnesses.InCh.2

wediscussedgamificationinthecontextofhealthcareandtheself-managementofchronic

illnesses,specificallydiabetes.Moreover,theresearchprocessandanoverviewofthe

methodologyusedinthisstudywerediscussedinCh.3.

Inthischapter,weanswerthefirstresearchquestioninthisthesis:

RQ1:Whatisanappropriateframeworkforgamifyingtheself-managementofchronic

illnesses?

Toanswerthisquestion,aframeworkforgamifyingtheself-managementofchronicillnessesshall

beintroduced.Theframeworkwillbebasedonwhathasbeenfoundfromtheliteraturereview

regardinggamification,andhowitmightberelevanttotheself-managementofchronicillnesses.

Theframeworkwasvalidatedthroughamixed-methodapproach.

4.1 Background

Asdiscussedintheliteraturereview(seeSec.2.3),gamificationhasbeenreceivingagreatdealof

attentioninthehealthcareindustry.Thisriseofthisinterestmaywellbeattributedtothefact

thatitisperceivedbymanythattheuseofgamificationcanbenefithealthcareintermsof

increasingengagementinhealthcare,preventivehealthcare,medicationadherence,andself-

management.Inparticular,self-managementiscrucialtothehealthofindividualslivingwith

chronicillnesses.Thesetasksmightbemadeeasybytheuseofgamification.However,itis

importanttobaseanycombinationbetweengamificationandtheself-managementofchronic

illnessesoninformedresearchgivingtheseriousnessofsuchillnesses.Additionally,itisimportant

tounderstandtheneedsofindividualswithdiabetesintermsofself-managementinorderto

incorporategamificationintoit,thus,tailoringittothisspecificenvironment.

Althoughthereexistsomeappsfortheself-managementofchronicillnessesthatutilisesome

aspectsofgamification(PBLsystem),itisnotcleariftheseappshavefollowedaframeworkor

guidelinesthatarespecifictothistask.Infact,thereexistsnosuchframeworkintheliteratureas

mentionedpreviously.Theexistingframeworksintheliteraturearemainlyfocusedonbusiness

andmarketing(seeSec.2.1.5).

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Theproposedframeworkthatincorporatesgamificationandtheself-managementofdiabetes

shouldenablethefollowingaspects:

• Empowerpatientstotakegoodcareoftheirhealth.

• Increaseadherencetomedication.

• Fulfiltheneedtobepartofacommunitythatsharethesamegoalsandchallenges.

• Encouragebetterself-managementhabits.

• Encourageconsistentloggingofdata(e.g.bloodtests,foodintake)

• Turnself-managingachronicillnessfromamundanetaskintoafunactivity.

• Provideconsistentandinformativefeedbacktousers.

4.2 FrameworkDesignProcess

Priortobuildingtheframework,aliteraturereviewwasundertakenonthethreedomains

identifiedbytheauthortobethemainareasofresearch,namelygamification,chronicillnesses

self-management(focusingondiabetes),andbehaviouralchangemethods.Thethreeareasand

theirintersectionareillustratedin

Figure4-1.Theframeworkisaresultofthecarefulreviewandanalysisoftheseareas.The

relationsbetweenthethreeareaswerestudiedandanumberofelementsweresynthesised.

Theseelementsformthebasisoftheframework.

Figure4-1TheThreeMainAreasofResearch

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4.2.1 TheElementsandThemes

Theresearchersynthesisedtwenty-eightelementsfromthethreedomainsshowninFigure4-2.It

isimportanttonotethattheterm“elementoftheframework”isdifferentfromthatof“game

elements”.Theelementsintheframeworkcomefromgamification,thepsychologyof

gamification,andself-management.Theseelementsarelistedin

Table4-2,Table4-1,andTable4-3.Thetablesshowtheelementsbasedonwhichpartofthe

literaturetheyareextractedfrom.

Inparticular,fromthegamificationparttwelveelementswereextracted(Table4-1),fromthe

self-managementpartoftheliteraturereviewsevenelementswereextracted(Table4-2),and

fromthepsychologyofgamificationpartnineelementswereextracted(Table4-3).

Asdiscussedintheliterature,thereisanoofaframeworkforthegamificationoftheself-

managementofchronicillnesses(seeSec.2.1.5).However,thesynthesisedelementswillbeused

toconstructaframeworkthatfillsthisgap.

Table4-1Alistofelementssynthesisedfromtheliteratureonthehealthcareofchronicillnesses

HealthcareofC

hron

icIllnesses

Logbook:anelectroniclogbookwhereuserscansavetheirbloodglucosetest

resultsandassociatedinformation.

Visualisationofdata:Loggeddatarepresentedinavisualwaysuchasin

graphs.

Trendsalert:pop-upmessagestohighlighttrendsintheloggeddata.

Peer-support:amechanismthatenablesuserstoaccesseachother’saccounts

andsupportthem.

Community:amechanismthatenableuserstointeractandcommunicate.

Socialmedia:amechanismtolinkthesystemuserstoothersocialmedia

platforms.

Sharing:amethodtoallowuserstoshareinformationabouttheir

achievementsortheirlogbookdata.

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Table4-2Alistofelementssynthsisedfromgamificationliterature

GameElem

entsand

Dyn

amics

Badges:graphicalsymbolsthatrepresentanelectronicmedallionforapre-

definedaccomplishment.

Points:countersthattrackthespecificactivitiesoftheuser.Theseactivitiesare

definedbythedeveloperandwoulddifferbasedonthecontext.

Challenges:Obstaclesdesignedinthesystemfortheusertoovercomewitha

timelimit.

Competitions:isadynamicelementthatresultsfromcollectpointsandbadges

torankupinleaderboard.

Feedback:amechanismtoshowusersinstantcommentsontheiractivities,

achievements,orengagementwiththesystem.

Leaderboards:aconstructthataccumulatestheuser’sachievementsand

comparesthemwithotherusersinthesystemandthenranktheusers.

Levels:aspaceinthesystemthatcanbereachedaftercompletingaspecific

setofactivitiesandcollectingaspecificnumberofpoints.

Storyline/themes:anarrativethattiesinallaspectsofthesystemandcreates

acontextfortheuser.

Reputation:Thisisanelementthatarisesdynamicallythroughtheinteraction

withthesystemandthecommunity.

Goals:milestonessetbythesystemandtheuser.

Avatars:graphicalrepresentationofone’sself.

Progressbar:agraphicalrepresentationofuserprocess.

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Table4-3Alistofelementssynthesisedfrombehaviourandgamificationliterature

Psycho

logyofG

amificatio

nIntrinsicmotivation:internaldriversofbehaviourthatcanarisedynamicallyin

thesystemordirectlyimplementedit.

Extrinsicmotivation:externaldriversofbehaviourthatcanbeimplementedin

thesystem.

Flow:atheorythatisusedinthesystemtoincreaseengagementbygradually

increasingthedifficultyoflevels.

Nudge:atheorythatisusedinthesystemtodirecttheusertowardsadesired

behaviour.

Babysteps/tinyhabits:atheoryusedtobreakdowntasksandactivitiesinto

smallersteps.

Autonomy:freedomofchoiceswithinthesystem.

Ability:theuser’scapacitytoperformingtasksandactivitieswithinthesystem.

Purpose:linkingthesystemtothebiggerpicture(i.e.health).

Trigger:actionstoreminduserstobeengagedwiththesystem.

Theseelementscanbefurthersubdividedintomorespecificthemesthatserveacommon

purpose.Forexample,collectingpointsandbadges,andparticipatinginchallengesand

competitionscanbeenjoyableactivitiesthatcancreateagame-likeenvironment,whichwecall

thefuntheme.

Theresearcherobservedthattheelementsfallintoeightthemes.Theseare:Fun,Socialising,Self-

representation,Self-management,Motivation,Growth,Esteem,andSustainability.Therestof

thissectiondiscussesthethemesandcombinesthemtocreatetheproposedframeworkforthe

self-managementofchronicillnesses.Thethemesandtheircorrespondingelementsare

illustratedinFigure4-2.

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Figure4-2TheEightThemesandtheirElements

Thefunthemecoversthebasicelementsforgamification.Thefourelementsofthefuntheme

couldgiverisetoafunenvironmentwheretheuserisengagedwiththesystemtocollectpoints

andengageincompetitionsandchallenges.Badgesandpointssignifytheuseofrewardsto

encouragepositivebehaviourintheself-managementofachronicillness.Userscanberewarded

forkeepingalogbookoftheirtestresultsandrelatedinformation,andtheirengagementwith

otherusers.Moreover,creatingchallengesandcompetitions(thatarenotrelatedtotestresults

orthemedicalinformationoftheuser)couldincreasetheengagementofusers.Thesecaneither

bebetweenusersorbeself-challengesforusers.

Themotivationthemecoversthetwotypesofmotivationsconsideredingamification.Thefirst

typeisintrinsicmotivation,whichistheinnatedesiretodosomething.Thistypeofmotivation

canbecultivatedthoughtheuseofmasteryandusingacombinationofotherelementssuchas

autonomyandpurpose.Thesecondtypeisextrinsicmotivation,whichisdoingsomethingonlyif

thereisareward.Thistypeofmotivationcouldbecreatedthroughtheuseofrewardssuchas

pointsandbadges.Thiscouldmakepeoplebecomeinterestedindoingacertainact(i.e.keepa

logbookoftheirdailyglucosetests).Incorporatingintrinsicandextrinsicmotivatorscouldsustain

thisinterest.Moreover,therewardsusedshouldbetailoredtothetargetpopulationsothatthey

arerelevantandvaluable.

Thesocialisationthemecoversfourelementsthatcreateasocialenvironment.Thissocialaspect

isthoughttobeimportantforgamificationandespeciallyforself-managingachronicillness.The

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61

elementsofthisthemeaddtothevalueofthefunthemeelements.Moreover,beingina

communitythatunderstandswhattheuserisgoingthroughcouldprovidethepsychological

supportneededbytheuser.Itwasmentionedpreviouslythatitiscommonfordiabeticpatients

togetclinicallydepressed.Thus,wegatherthatitisimportanttoprovideamediumwherethey

canshareandreceivesupportfromtheirpeers.Moreover,Maslow’sHierarchyofNeeds(seeSec.

2.2.1.4)indicatestheimportanceofhavingasenseofbelonging.

Theesteemthemecoverstheelementsthatcouldcreatefeelingsofvalueandrespect.Basedon

Maslow’sworkitisbelievedthatpeopleneedtoberespected,feelgoodabouttheir

achievementsandhaveself-worth.Somepeopledothingsfortherecognitionandtobevalued.

Mostgamificationelementsareesteemboosterswhendesignedfortherightcontext.

Furthermore,asusersseetheirnamemovingupinaleaderboard,astheirprogressbaradvances,

orastheyaccumulateofanumberofbadges,itcouldsatisfytheirneedforrecognitionand

positivelyaffecttheirself-esteemingeneral.

Theself-representationthemecoversfourelementsthatcouldcreateaconnectionbetweenthe

userandthegamifiedapp.Also,representingtheuser,theirgoals,andtheirabilitiesinthe

gamifiedsystemisimportanttoincreasetheengagement.Thiscouldbeachievedpartially

throughprovidingcustomizedprofilesandavatars.Inaddition,givingusersthechancetosettheir

owngoalssuchasglucoselevelgoalswillenhancetheirsenseofautonomyandwilltailorthe

experiencetothem.Theseincludepositivemanagementhabitssuchaskeepingarecordofdaily

testsandbeingawareofone’sprogress.

Thesustainabilitythemecoverstheelementsthatensuresustainabilityofgamificationeffects.

Theseelementsarederivedfromgamedesignandbehaviouraltheories.Theflowelementis

basedontheflowtheory,thenudgeelementisbasedonthenudgetheory,thetriggerelementis

basedonFog’sbehaviouralmodel,andstoryline/themeelementbasedinMDAframework

(discussedinSec.2.2andSec.2.1.1).Havingflowandastorylineorathemecouldbeeffectivein

capturingthelong-termattentionofusersinvideogames.Inaddition,triggerandnudgeare

behaviouraltheoriesthatarebelievedtoshiftthebehaviouroftheusertothedesireddirection.

Inthiscontext,usingthenudgetheoryandtriggersmayreinforcepositivebehaviourinmanaging

diabetes.

Thegrowththemecoversthepersonalgrowthofpeoplewithchronicillnessesintermsof

managingtheirillness;learningnewhealthyhabits,andachievingtheirself-managementrelated

goals.Oneofthemostimportantaspectsofthesuccessofgamificationisprovidingreal-time

feedbackthatismeaningfulandrelevanttousers.Moreover,inthecontextofself-managing

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illnessesthiscanbeuseful.Feedbackcanberepresentedinmanyways,includingrewardsand

incentives,whichgiveimmediatefeedbacktousersabouttheirperformance.

Theself-managementthemecoversthebasicelementsforself-managingachronicillness.The

logbookistohelpusersinkeepingatrackoftheirbloodglucosetestresultsforexamplesand

relatedinformation.Thevisualisationofdataelementtakestheinformationfromthelogbook

andpresentsitingraphs.Throughprovidingfeedbackintermsofgraphsofbloodteststheuser

willlearnabouthis/herconditionandwillrecognizeanypatterns.Moreover,thealertelement

indicatesalertingtheuserwhentheirbloodglucosecontinuestobelowerorhigherthanaverage

forexample.

Table4-4listtheeightthemesthatconstitutetheframework.Thetablealsoprovidea

summariseddefinitionofeachtheme.

Table4-4TheWheelofSukrThemes

Themes Definition

Self-

management

Basicelementsneededtoself-monitorbloodglucose,includingtrackingmeasuresof

bloodglucose,insulin,foodintake,andotherrelatedinformation;gettingfeedbackbased

ontheentries;andbeingnotifiedwhenbloodglucosemeasuresfluctuate.

Socializing Beingpartofagroupofpeoplethatsharesthesamesituation,whichofferssocialand

emotionalsupportandaddstothevalueofrewards.

Self-

representation

Tailoringtheexperiencetocreateabondwiththeuser,thusincreasingengagementand

creatingameaningfulexperience.

Fun Creatingagame-likeexperience.

Esteem SatisfyingthefourthlevelofMaslow’sHierarchyofNeeds,thuscateringtothe

psychologicalsideofmanagingdiabetes.

Motivation Appealingtothedesiretodothings.

Sustainability Theabilityofthesystemtomaintainthesamelevelofengagementtosustainthedesired

effect.

Growth Creatingafruitfulexperiencefortheuser,wheregamificationinasocialandpsychological

contextcanresultinpersonalgrowthintermsofmanagingdiabetes,learningnewhealthy

habits,andunderstandingthediseasebetter.

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4.3 TheWheelofSukrFramework

ThethemesandtheirassociatedelementsaresynthesizedintoaframeworkthatwecallThe

WheelofSukr(Figure4-3).Theword‘Sukr’meanssugarinArabicanditisalsoacommonwayto

refertodiabetesinSaudiArabia.Theshapeofthewheelwaschosentoreflecttheimportanceof

allofthethemestogether.Atthisstageweassumethatthethemesareofequalimportance.

Toourknowledge,thisisthefirstframeworkthattargetstheuseofgamificationintheself-

managementofchronicillnesses.Asdiscussedearlier,TheWheelofSukrcombineselements

fromgamification,self-managementpractices,andbehaviouralmethodstocreateanengaging

andfunself-managementexperience.

TheWheelofSukrproposesawaytoutilisegamificationandbehaviourchangemethodsinthe

self-managementofchronicillnesses.Throughtheuseofmotivation,rewards,positivefeedback

andpeersupport,apositivebehaviourinmanagingchronicillnessesisaimedtobereinforced.

Thepositivemanagementhabitsincludekeepingarecordofdailytestsandbeingawareofone’s

progress.Furthermore,theuseofconceptsunderlinedintheframeworkmightallowusersto

realisepatternsandmakedecisionsaccordingly.Thiseventuallycouldleadtoanincreaseinthe

feelingofautonomyontheusers’sidegivingthemasenseofcontrolovertheirowncondition.

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Figure4-3TheWheelofSukr

4.4 ValidationoftheWheelofSukr:Mixed-Methods

Methodologicaltriangulationwaschosenasthemixed-methodresearchapproachforvalidating

theframework[Figure4-4].Asshowninthefigure,theframeworkisvalidatedusingthreesteps.

First,theliteraturereviewprovidedelementsthathavebeenshowntoworkinthefieldsof

gamification,self-management,andpsychologyofgamification.Then,thethemesofthe

frameworkwerevalidatedusingbothexpertinterviews,andaquestionnaire.Theexpert

interviewsandthequestionnairewereconductedtoconfirmtheinclusionofthethemestocreate

aframeworkforgamifyingtheself-managementofchronicillnesses(specificallydiabetes).

Figure4-4ComponentsofTriangulationforFrameworkValidation

Theinterviewswereconductedwithagroupofmedicaldoctors,psychiatristsandpsychologists,

andgameandgamificationexperts(seeSec.4.5).Ontheotherhand,anonlinequestionnairewas

answeredtoindividualswithdiabetesbasedinSaudiArabia(seeSec.4.6).

Itisessentialtoobtaintheinsightofdiabeticdoctors,psychologists,andpsychiatristsonthe

framework,alongwiththefeedbackofgamificationandseriousgamesexperts(See2.1).This

enablethevalidationoftheframeworkholistically.Moreover,thequestionnaireprovidedthe

inputofpeoplewithachronicillness(peoplewithdiabetes)ontheframework’sconcept.Thisis

consideredtobecrucialinvalidatingtheframework.Itpermitsmeasuringparticipants’attitudes

towardstheframework,andifitmeetstheirneedsonceitisappliedtoself-managementtools.

Thus,byconductingbothstudiesweaimtovalidatetheframeworkandmeasurethelevelof

acceptanceofgamifiedself-managementapplications,andunderstandwhatmightbelacking

fromtheirpointofview.

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65

EthicalapprovalsforbothstudieswereobtainedfromtheEthicsCommitteeoftheUniversityof

Southamptonpriortoconductingtheinterviewsandquestionnaires(referencenumbers:

ERGO/FPSE/14208andERGO/FPSE/15296).

4.5 Study1:ExpertInterviews

Inthissection,thefirststudyforthevalidationoftheframeworkisdiscussed.Theobjectiveofthe

interviewsistovalidatethethemesoftheframework.Thesectionisdividedintotwoparts.First,

theinterviewdesignandprocessarediscussed.Then,thefindingsoftheinterviewsare

presented.

4.5.1 Interviews DesignandProcess

Theinterviewswereconductedwithdoctorsspecialisingindiabetes,psychologistsand

psychiatristswhohaveworkedwithindividualwithdiabetes,andgameandgamificationexperts.

Theaimoftheexpertinterviewswastovalidatetheproposedframeworkfromthreedifferent

perspectivesthatreflecttheareasofresearch(see

Figure4-1).

TheWheelofSukrframeworktargetstheself-managementofchronicillnessesandspecifically

diabetes,whichischosentolimitthescopeofthisstudy.Sincetheframeworkisdesignedforthe

self-managementofdiabetesitwasessentialtoconsultexpertswhohavemedicalknowledgeof

theillness,theself-managementitrequires,andhavedirectexperiencewithindividualswith

diabetes.Thisisreflectedinthesampleoftheinterviews.Theyunderstandwhatisnecessaryto

self-managetheillnessproperly,thestrugglesthattheirpatientsface,andthepsychological

difficultiesoflivingwiththiscondition(i.e.motivation,behaviourmethods,cognitivebehavioural

therapy,andpeer-support).

Eightexpertswerecarefullyselectedbasedontheirexperienceintheirfields.Then,theywere

thencontactedbyemailandinperson,andtheinterviewswereconductedface-to-face.The

doctors,psychologists,andpsychiatristswhoparticipatedinthestudywereselectedfrommajor

publicandprivatehospitalsinRiyadh,SaudiArabia.Thoseexpertswerechosenbasedontheir

experiencewiththediabeticcommunityinSaudiArabiaandtheirexpertiseinthisarea.

Moreover,asdiscussedearliergamificationhaselementsextractedfromgames.Theseelements

arethoughttobewhatmakegamesengaging.Thus,twoPhDresearchersfromtheUniversityof

Southamptonwithexpertiseingamificationandgameswereselectedtovalidatethethemesof

theframeworkinanopen-endeddiscussion.

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Whileinterviewsareveryvaluable,however,itisimportanttomentionthattheyrequirea

significantamountoftimetoarrangeandconduct.Thisconsistsofseveralstepsincludingthe

identificationofpossibleparticipants,contactingstage,arrangementofasuitabletime,and

conductingtheinterviewitself.Inthisstudy,theresearcherconductedmostoftheinterviewsin

SaudiArabiatomeetwiththemedicalandpsychologyexperts.Interviewscanbeveryexpensive

intermsoftimeandfunding.However,itwasworthwhileandtheexpertschosenareatthetop

oftheirfields.Theexpertsinthestudywere:

• Achairprofessorinpsychiatrywithexperienceinworkingwithdiabeticindividuals.This

expertisbasedinoneofSaudiArabia’smajorhospitals.Theexperthas20yearsof

experience.

• Aprominentconsultantpsychiatristwithextensiveexperienceincognitivebehavioural

therapy.

• TwodiabetesandendocrineconsultantsinoneofSaudiArabia’sbiggesthospitalslocatedin

Riyadh.Oneisanexpertinchildandadolescentdiabetes.Bothhavemorethan10yearsof

experience.

• AdiabeteseducatorexpertfromofamajorSaudihospital.

• AnutritionexpertfromthenutritionclinicofamajorSaudihospital,whoisspecializingin

workingwithindividualswithdiabetes.

• TwoseniorPhDresearchersfromtheUniversityofSouthamptonwithexperiencein

gamificationandgames.BotharepartoftheGameDesignHubattheUniversityof

Southampton.

Inqualitativestudies,thesizeofthesampleisaffectedbythesaturationofdata.Whenthedata

collectedstartstobecomeredundant,itmeanstheinterviewshavereachedthepointof

saturationandnomoreinterviewsneedstobeconducted(GuestandJohnson,2006).Theoverall

totalnumberofexpertswaseight[Table4-5],andnomoreexpertinterviewswererequiredsince

thedatafromtheinterviewsapproachedthesaturationlevel.

Table4-5InterviewExperts

Diabeticdoctors Experts#1#3#4#8

Psychologistsandpsychiatrists Experts#2#5

Gameexperts Experts#6#7

Atthestartoftheinterview,thepurposeofstudyandtheprocessbywhichtheinterviewwillbe

conductedwereexplainedtotheintervieweetoclarifyanyambiguities.Eachexpertwas

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presentedwiththeparticipantinformationsheetandconsentformtosign.Theinterviewswere

audiorecordedforthetranscriptionandanalysis.

Asemi-structuredapproachwaschosenfortheinterviews(Sec.3.1.1.1).Eachinterviewconsisted

oftwoparts:asetofclosedquestionsaboutthegeneraldomainthatisintendedtosetthestage

andfocusthediscussionontheconceptsunderlyingtheframework,andasetofopen-ended

questionstostartthediscussion(AppendixA).Theexpertswereaskedquestionsbasedontheir

areaofexpertise,anddiscussedtheunderlyingconceptsoftheframeworkaswellasanyextra

pointsthattheycouldprovidebasedontheirfield.

Oncethedatawascollecteditwasanalysedusingacodingsystembasedontheeightthemesof

theframework.Thismethodiscalledadeductivethematicanalysis,whichisusedinorderto

confirmordisproveapre-existinghypothesisasopposedtoaninductivethematicapproachin

whichtheresearchertriestodiscovernewpatternsorestablishanewtheory(BraunandClarke,

2006).Thedeductiveapproachwaschoseninthisstudysincewehaveestablishedaframework,

andthisstageisconcernedwithconfirmingthattheframeworkandtheconceptsunderlyingitare

validfromthepointofviewofmedicalexperts,gamificationexperts,andusers.

Giventhatthenumberoftheinterviewsismanageablethecontentofthetranscribedinterviews

wasanalysedmanually.Thiswasdonebygoingthroughthecontentofeachinterviewand

dividingthedataintoeightgroupsaccordingtothepre-existingthemes(thethemesofthe

framework).Datathatdidnotfalldirectlyunderanyoftheeightthemeswereputintoaseparate

categorycalled“otherresults”.Thisdatawasoutsidethescopeofthisresearch(medicalexperts’

concernsregardingdiabeteseducationandawareness),however,itwasdividedintoanumberof

topicsandithelpedindirectingfuturework(seesec.6.2)

Toensurethatthereportingoftheinterviewsfindingsisunbiasedandobjectivethefollowing

stepsweretaken:

Ø Theresearcherreportedtheoutcomeofeachpre-selectedthemewithoutdiscardinganydata.

Ø Theresearcherusedverbatimquotesrepresentingtheopinionsoftheexperts.Ø Duringtheinterviewtheresearcherensurednottoinfluencetheexpertsbymentioning

thebenefit,advantages(perceivedbytheresearcher)ordiscusstheresearcher’sopiniononthesubjecttoinfluencetheoutcome.

Ø Theresearchertookalistenerpositionandguidedthediscussiontouncovermoreinformationbasedontheknowledgeandexperienceoftheexperts.

Inthefollowingsectionthefindingsofthethematicanalysisoftheinterviewsarepresented.

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4.5.2 InterviewsFindings

Thedoctorsandeducatorsondiabetesprovidedvaluableinformationbasedontheirimmediate

experiencewithdiabeticsinSaudiArabia.Similarly,thepsychologistsandpsychiatristsprovided

insightintothepsychologicalissuesthatdiabeticsfaceinSaudiArabiathatcanaffecttheirself-

management.Asforgameexperts,theirinputwasspecificallyfocusedontheelementsderived

fromgamificationliterature.Theoverallfindingsoftheinterviewsprovidedthevalidationofthe

WheelofSukr.

HerethefindingsanddiscussionoftheinterviewsbasedonthethemesoftheWheelofSukris

presented.

Fun

Thefunaspectofgamificationoftheself-managementofchronicillnesseshasbeenestablishedin

theliteraturesincethePBLsystem,ifintegratedwiththeotherthemes,cancreateanexperience

thatisenjoyablefortheuserwhileperformingtheirimportantself-managementtasks.The

findingsoftheinterviewssupportthisaspectoftheframework.Theideaofcreatinganenjoyable

experiencefordiabeticpatientswasstronglywelcomedbyexperts.AsExpert#3said:

“Naturallypeopleliketoberewarded.Thus,ifthisisappliedtotheself-managementof

diabetesitwouldbeveryeffective.”

Whileitisdifficulttotesthoweffectivetheframeworkwillbeonceitisimplemented.Thisindeed

requiresanotherstudythataimstomeasuretheeffectiveness,whichisoutsidethescopeand

aimofthisstudy.However,theliteraturesuggeststhattherewardingaspectisoneofthe

essentialpartsofwhatmotivatespeople.Thismeansrewardsthatariseinthefunenvironment

(e.g.receivingpoints,badges,andhigherrankingoftheleaderboardintheself-managementapp)

itisanimportantpartoftheframework.

Moreover,Expert#3alsomentionedthatsuchafunenvironmentcouldhaveapositiveeffectin

thewaythattheuserperceivestheself-managementtasks.Astheystatethat:

“Itwillchangetheviewandtheexperienceofself-managementofdiabetesforthe

patient.”

Indeed,self-managementisveryseriousprocessandrequiresrepetitivetasksandthisnaturecan

bedauntingandboring.Thefunthemeshouldbeabletodealwithissuesandalsocouldhelpthe

self-esteemofusersasExpert#5said:

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“Positiverewardisenjoyableinwhicheverformitcomes.Thiswillhelppatients’self

esteem.”

Furthermore,Expert#8whoregularlyparticipatesineventsfordiabeticpatientssaid:

“Usinggames,competitions,andfuneventshaveshownapositiveeffectondiabetic

patients.”

Thissuggeststhatcreatingagame-likeexperiencethatentertainstheuserscanbearelevantpart

toimprovingtheself-managementprocess.

Socializing

Theabilitytosharethesameexperiencesandconcernswithotherindividualwithdiabetescan

offerthesocialandemotionalsupportthatanindividualwithdiabetesneeds.Itcreatesagood

environmentforgamificationwheretheexistenceofasocialcommunityaddstothevalueof

rewards,competitions,andmotivation.AsExpert#2pointedout:

“Intoday’sworld,theeffectsofsocialmediaonyoungandearlyadolescentsisverybig.

Infact,itcouldleaveastrongerimpactonthepatientthanthatofthedoctor.”

Duetothat,addingthesocialaspectinagamifiedappcanhaveawiderangeofimpactsonthe

experienceoftheuser.Thisimpactcanbeverypositiveifitallowstheuserstolearn,share,and

feelasapartofacommunity.Thisaccordswithwhathasbeenfoundintheliteratureonthe

importanceofcommunityindiabetesself-management.Additionally,beingpartofacommunity

canhelppatientsovercomethestigmasurroundingtheillnessesasconfirmedbythesame

expert.

Expert#1(endocrinologist)stressedthatthecommunityshouldbeexclusivetodiabeticusers.The

expertpointedoutthatincludingotherswhodonothavediabetesmightresultinthespreadof

wronginformationabouttheillnesses,andthatthepatientwillonlybenefitiftheusersofthe

communitysharedtheirunderstandingoftheillnessesandexperience.Additionally,the

communitywillbenefitfromuserswhoareeducatedabouttheirillnessintermsofmedication

andself-management.Theexpertmentionedhispersonalexperiencewithpatientswho

mismanagetheirillness.Inparticular,somepatients,accordingtothedoctor,failtotaketheir

medicineandmaintainthebloodglucosethatisrecommendedtothem,becausetheycanbe

easilyinfluencedbyfamilyorfriendswhodonothavediabetesandhavemisconceptionsaboutit.

Thus,thedoctorsuggestedthatthecommunityshouldbediabeticonly.

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Thedoctoralsohighlightedtheimportanceofcreatingadiabeticsocietywherediabeticscan

interactandbeactivemembers.However,andaccordingtothedoctor,somepatientsare

reluctanttoparticipateindiabeticeventsortalkabouttheirillnesspublicly.Thedoctorsaidthat

heandhiscolleagueshavetriedtocreatediabeticeventsondiabeticday,forexample,buta

limitednumberofpeoplewouldshowup.Thisgivestheimpressionthatanonlinecommunity

mightbeagoodoptionfortheSaudicommunity.Thisinformationwassupportedbyanother

expert(psychiatrist),whopointedoutthevalueofpeersupporttothepatient.Thepsychiatrist

saidthatpeersupportisimportanttoeveryonebutespeciallyimportanttothoselivingwith

chronicillnesses.Theexpertdiscussedtheeffectthatdiabetescanleaveonsomepatientsin

termsofbeingsociallyshyandhidingtheirillness(i.e.nottakingmedicationinfrontofpeopleor

ignoringtestingbloodglucosebeforeandaftermealsifpeoplearearound).Thus,theexpert

stressedthattheuseofonlinecommunityisimportantbecauseitgivepatientsthesupportthey

needwhilestillkeepingtheirprivacy.Theexpertsaid:

“Ibelievethattheeffectofpeersupportisimportantifitisprovidedtothepatientinan

onlineform.Ibelievethiswillfacilitateeaseofcommunicationespeciallytothosewho

areshyabouttalkingabouttheirillnessandprefertokeeptheirprivacy.Onlinetheycan

communicatewiththeirpeersknowingthattheysharethesameexperienceand

understandwhattheyaregoingthroughbuttheycanstillkeeptheirpersonal

informationprivatewhichiscomfortingtoalot”.

Therefore,thesocialandcommunityaspectoftheframeworkcanbeessentialinproviding

supportfordiabeticsandintyinginalltheotherthemesoftheframework.

Esteem

Oneoftheexpertsmentionedthatitisimportanttokeeptheusersontopoftheirprogressso

thattheycanhavebetterhandlingofself-care.Thiscanbeachievedbytheprogressbarfor

example.TherewardingaspectthathasbeendiscussedintheFunthemesection,alsoappliesfor

theesteemthemesinceLeaderboards(aspartofgamification)arebasedonrankingandusers

whoachievehigherrankscanfeelrewarded.Thiscouldenhancetheirself-esteemandtheirview

ontheirself-management.

Additionally,themedicalexpertsdiscussedthestigmaondiabetesinSaudiArabia.Themedical

expertstalkedabouttheeffectofsocietyandsometimesparentsandfamilyontheself-esteemof

theindividualwithdiabetes.Someparentsandfamilyofdiabeticindividualsenforcethisbybeing

overprotectiveoftheirdiabetickids.Someexpertsexpressedthatsomeoftheiryoungpatients

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haveoverprotectiveparentswhodonotallowthemtogooutwithfriendsoreatoutsidethe

houseandthusaffectingtheirself-esteem.Thisaffectstheirself-management,asExpert#8said:

“Howthepatientfeelsaboutdiabeteshasagreateffectontheirself-management.”

Anotherexpert(psychiatrist)saidthatadolescentsandyoungadultswithdiabetesmayhavelow

self-esteembecauseoftheillness,andmightrebelagainsttheirparentsandfamiliesbystopping

medication.Theexpertexplainedthatthishappensbecauseadolescentsandyoungadultsfeel

isolatedduetohavingdiabetes(andbecauseitisnaturalforteenagerstowanttobeindependent

andgetridofalltherestrictionsbuthavingthisillnessispartoftherestrictions).Theexpert

indicatedthatitisessentialtofocusontheelevatingtheself-esteemofindividualswithdiabetes

andmotivatingthemandthathiswillleadtobetterself-managementandadherenceto

medication.

Therefore,aself-managementappfordiabetesshouldtakeintoaccounttheself-esteemofthe

patient.Self-esteemcanbeaddressedingamificationbycompetitions,leaderboards,levels,and

progressbars.Creatingcompetitionsbetweenpeersandaddingleaderboards(community/

trackingprogresscomparedtoothers),levels(individual),andshowingprogressbars(individual)

inaself-managementtoolcouldbeessentialinboostingusers’self-esteem.Thismightfulfilthe

needforrecognitionandinstantpositivefeedbackwithinthehumannature.Thiscouldresultin

positivechangeinbehaviourregardingtheself-managementofdiabetes.

Self-Management

Accordingtosomeexperts,somediabeticsfeelstigmatizedandcouldbeshytodealwiththeir

conditionwhentheyareparticipatinginsocialactivities.Thisinturncouldpreventthemfrom

maintainingtheirdailyself-managementroutines,forexample,missingtakingbloodglucosetest

results.However,expertsarguedthatsomefamiliesplayanegativerole,whichprevents

individualswithdiabetesfromself-managingdiabetesproperly.ThiswassupportedbyExpert#3

whosaid:

“ThestigmaondiabetesinSaudiArabiaaffectstheabilityofsomepatientstoperform

thedailyself-managementactivitiesinpublicoraroundotherpeople.”

Thisshowsthattherearesomedifficultiesfacedbyindividualswithdiabetesintermsofdealing

withdiabetesself-managementtasksinpublic.Furthermore,expert#1expressedthatthemain

challengethathefacesistheeducationandawarenessofpatients.Partofwhathediscussedis

theimportanceofdailyself-managementathome.However,thedoctorsaidthatsomeofhis

patientsdonotrealisethevalueofthedailyself-managementandtheirroleinimprovingtheir

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health.Hesaid“somepatientsarenotkeentolearnaboutdiabetesandtheself-managementof

if”,andthattheymainlyrelyontheirdoctor.Thedoctoragreedthatsomepatientsneedmore

motivationtoself-managetheirillness.

Additionally,theexpertsaidthatinthecountryheworkedinbeforecomingtoSaudiArabia,

manypatientswouldcomewithalogbookoftheirdailytestandgraphsandpiechartsofthe

results.Anappthatshowsavisualizationofdailyloggedtestresults(e.g.graphs)notonlywould

benefitpatientsandhelptheminself-managing,butalsohelptheirdoctorsintreatingthemand

makinginformeddecisions.Thissupporttheneedofanelectronicself-managementlogbookin

Arabicthatnotonlyhelpuserskeeptheirdailytestsbutalsovisualizethedataingraphsandpie

chartsandshowtrends.Thiswillhelpempoweringthepatientandgivingthemautonomyover

theirownhealthandhelpthedoctorsmakeinformeddecisions.

Infact,theexpertmentionedthatmanyindividualswithdiabetesarenotawareofexistingself-

managementtoolsforexample.Thismightbebecauseoflanguagebarriersorbecausetheyhave

underestimationofthequalityofapps.Indeed,anappthatisplainandsimplemighthavelittle

chanceofattractingsuchindividualsasopposedtoagamifiedapp.

Therefore,agamifiedself-managementtoolshouldenableuserstoself-managewitheaseand

confidenceandwithoutembarrassmentordelay.Theframeworkthemescollectivelycould

achievethisbyraisingtheusers’awarenessoftheimportanceoftheself-management.For

example,showingthemgraphsorpiechartsoftheirtestresultscouldmotivatethemtokeepon

topoftheirhealth,nudgingthemintotakingthetestsoradheretotheirmedicine,andbe

encouragedbyotherindividualsfromtheircommunitywithintheapp.

Motivation

Themajorityofexpertsagreedthatmanydiabeticpatientslackmotivationintermsofself-

management.Thediabeticdoctorshighlightedthatthereisalackofmotivationinfollowingthe

rightproceduresforself-managementandcaringforoneselfamongsomepatients.BothExperts

#1and#3saidthatsomepatientsarenotmotivatedtolearnabouttheirillnessandlearnself-

managementskills.Thiscouldbealsorelevanttothe“growth”theme(discussedlater)inwhich

feedbackandprogressareessential.Expert#4expressedthatgameelementsandrewardscould

bethesolutiontothelackofmotivation,whichsupportsthe“fun”themediscussedearlier.

ThemedicalexpertsagreedthatitcouldbeverychallenginginSaudiArabiatomotivateindividual

withdiabetes,andafewofthemmentionedthattheyhavetriedtoorganizemotivationalgroup

eventsfortheirpatients.However,thereisusuallyverylittleattendanceandengagement.

Changingthisisverycrucial,andself-managementappswithgamificationthataredesignedto

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increasemotivationcouldhelpinthisregard.Indeed,Expert#2talkedabouttheimportanceof

motivation,theexpertsaid:

“Motivation,self-esteem,andacceptanceofcircumstancesareimportantfactorstofocusonin

ordertohaveabalancedviewofoneself”.

Furthermore,Expert#7said:

“intermsofmotivation,frommypersonalexperienceinresearchIthinkitisimportant

toprioritiesintrinsicmotivationoverextrinsicmotivation,becauseintrinsicmotivationis

themorelongerlasting…sogetthemtousethesystemwithextrinsicmotivationand

thenuseintrinsicmotivationtoletthemcontinueusingit.”

Therefore,agamifiedself-managementtoolshouldtakebothtypesofmotivationinto

consideration.Thisisthereasonwhymotivationisasignificantpartoftheframework.

Growth

TheexpertsagreedthatelementsoftheGrowththemesuchasFeedbackareessentialtotheself-

managementofdiabetes.Expertsassertedthatthefeedbackaspectofaself-managementappis

veryimportant.Thefeedbackcouldcomeinavisualformthatinformstheuserabouttheir

activitiesandthetaskstheyhaveundertaken,isanimportantaspectoftheapp.Moreover,as

mentionedinpreviouselements,thereisalackofmotivationinself-managementandalackof

consistency.Therefore,theGrowththemeisavitalpartoftheframework,andapplyingallthe

themescombinedmayhelpincreatingnewhabitsinself-managementofdiabetesandcreating

consistency.

Themedicalexpertstalkedaboutthedifficultytheyfacewithsomepatientsintermsofkeeping

upwiththeirself-managementroutinesandadherencetomedication,eventhoughthosesome

ofthosepatientshadbeendiagnosedwithdiabetesforayearormore.Thisindicatetousthat

theremightbeaproblemthatfacethosepatientsintermofcreatingthenewhabitsofself-

managingdiabetes.Thismightbeaddressedbythegrowththemeandspecificallythe“Baby

steps/tinyhabits”methodwhichcouldhelpinadoptingnewhabitsbybreakingthemintosmaller

tasksthatcanbecombinedwithdailyreunites.

Self-Representation

Somepatientscouldfeelthattheyarebeingblamedfornottakingcareoftheircondition;for

example,iftheirbloodglucosewashigherorlowerthannormal.However,ifthepatientswerein

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anenvironmentwheretheyareencouragedbyotherpeers,thenthiscouldhelpthemimprove

theirself-managingskills.Infact,Expert#2said:

“Peersandpeerrelationsareveryimportanttoyoungstersandadultsalikebut

especiallytothosewithspecialneedssuchaslivingwithdiabetes”.

Also,adolescentsmightbereluctanttotaketheirdoctors’instructionsresponsibly,possibly

becauseitcouldunderminetheirindependenceassuggestedbythesameexpert.Thisis

reinforcedbytheopinionofExpert#6:

“Iftheuserhasasenseofcontrolofwhattheyaredoing,theywillfeelthatthingsare

notimposedonthemandtheyaretheactors.”

Furthermore,oneexpertmentionedthatautonomyisveryimportantaspect,especiallyforyoung

adultswhousuallyseekindependence.Moreover,Expert#6indicatedthesenseofautonomy,and

thepurposeingamificationisimportantduetobeingincontrol,asopposedtohavingthings

imposedtheuser,andthismightincreaseengagement.Theexpertalsomentionedthattheuseof

anavatarcancreateidentificationtotheuserandkeeptheiranonymity.Additionally,whenasked

abouttheself-representationthemeanditsrelationtogamificationexpert#6said:

“itisextremelyimportantbecauseyouhavethesenseofconnectionwiththesystem”

Therefore,agamifiedself-managementappshouldprovideanenvironmentfordiabeticpatients

wheretheyfeelrepresentedandincontrol.Theenvironmentshouldallowthemtopursueand

achievetheirgoalsregardingself-managingdiabetes.

Sustainability

Sustainabilityisessentialtothesuccessofanygamificationapp.Maintainingthesamelevelof

engagementcanresultinthepositivechangeinbehaviourinself-managementofdiabetes.The

gameandgamificationexpertsagreedthattheuseoftriggersandnudgetheory,whicharethe

elementsofsustainabilitytheme,mightdirectusersintothedesiredbehaviourforself-

management.Oneexpert(gamificationexpert)suggestedthatnudgingtheusercouldhelpin

persuadingthemtocompletetasksofself-management.Theexpertalsosuggestedthatthe

storylineisanimportantaspectandcouldconnecttheotherthemestogether.Expert#6said:

“Thevisualpartisimportantbecauseyoucanhaveapleasurableexperiencewithan

interfacethatismorefamiliartoyouandithassomemeaning.”

Theexpertmentionedthat“theuserwilllearnthroughthesystemandwiththesystemsothey

don’tstayinthesamelevel”,whichiscapturedintheflowelementofthesustainabilitytheme.

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Moreover,theexpertdiscussedtherelationbetweentheSustainabilitythemeandtheGrowth

themehighlightingthatthelatterisrelatedtotheuser(intermsofprovidingtheuserwith

feedback,achievinggoals,andadoptingnewhabits),andtheformerisrelatedmoretothe

system(intermsofincreasingthedifficultyoftasks(flow),creatingtriggerstogettheuserto

performtasks,providingastorylineoratheme,andnudgingtheusertowantedbehaviour).

Furthermore,theexpertpointedoutthatNudgingtheusercanmaketheexperienceofusingthe

appeasierandquicker.Thus,byfacilitatingeaseofuseandprovidingtheuserwithinstant

feedbackitcanpersuadeandguidetheuserstoperformthetasksthattheyneedtodo.

Therefore,sustainabilitythemeisimportanttoaddresssomeoftheissuesrelatedtosustaining

theengagementanduserinterestintheapp.

OtherResults:

Duringtheinterviews,theexpertsdiscussedotherareasthatarenotnecessarilyrelatedtothe

themesortheaimoftheframework.However,theseareissuesthatconcernthemedicalexperts

regardingthediabeticcommunity.Theseadditionalcommentsareorganizedunderthreetags:

education,age,andnegativeconnotationaboutdiabetes.

Education:

Oneoftheendocrinologists,Expert#2,raisedtheissueofeducationwhilediscussingtheself-

managementofdiabetesandhisexperiencewithpatients.Theexpertstressedtheimportanceof

educationofdiabetesandhowtoself-manageit.Basedonhisexperience,thedoctorthinksthat

somepatientsarenotkeentolearnabouttheillnessandnotkeenonself-managingit.Thedoctor

saidthatsomepatientsdonotmeettheirdiabeticeducatorsanddiabeticnutritionist.Thedoctor

said:

“Theproblemthatfacesmeistheeducationofdiabeticpeopleaboutwhatisdiabetes

andhowtomanageit,andwhatarecomplicationsofit.UntilnowwhenIaskmy

diabeticpatientsabouttheirHbA1c(haemoglobinA1c)theydonotknowit.Theydonot

knowthevalueofitintheassessmentofdiabetes.Theydonotknowthevalueofself-

monitoringbloodglucoseathome.”

Thedoctoralsosaidthathespendsagreatdealoftimeteachingsomeofhispatientsabout

diabetesbecausetheydonotseetheirdiabeticeducators.Ashesaid:

“Someofthediabeticpatientsdonothavemotivationandnotkeentobeeducated.”

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Thedoctortalkedabouttheneedtoraiseawarenessnotonlywithdiabeticpeoplebutalsoabout

diabetestoenableotherstoavoiditbyhavingbetterdietanddoingsports.Expert#2saidthat

therearesomeeffortsinraisingawarenessandeducationregardingdiabetesthataretaking

placeinSaudiArabia.TheexpertexplainedthattheseprogrammesareArabicandaimtocreatea

channelbetweendiabeticsandexperts(endocrinologists,psychiatrists,andnutritionist)andthe

patientsandtheircarerstoenablethemtoaskquestionsandreceiveanswersfromtheexperts

usinganSMSservice.

Age:

Oneofthepsychiatrists,Expert#2,whohaveconductedstudiesontheeffectsofdiabetesonthe

psychologyandpersonalityofchildrenwithdiabetesinSaudiArabia,expressedthatitisessential

toconsideragewhendealingwithdiabeticpatients.Moreover,shesaidthatinordertohave

effectivecommunicationandpeer-supportbetweenusersitisimportantthattheyarefromthe

sameagerange.Theexpertalsoexpressedthattheuseofrewardsinthissensecouldbeeffective

onadolescentsandchildren.

Negativeconnotationaboutdiabetes:

Allthemedicalexpertsagreedonthepresenceofanegativeconnotationarounddiabetesinthe

community.Theexpertsmentionedthattheyfaceproblemswithsomeoftheirpatientswhodo

nottaketheirinsulinshotsiftheyareoutinpublicandaroundpeopleandendupmissingthe

medication.Otherssaidthatpatientsarereluctanttotesttheirbloodglucosebeforeandafter

mealsiftheyareoutinpublicandaroundpeople.Thisleadstothemnothavingadailyrecordof

theirbloodglucoseandalsonottakingtherightamountofinsulin.

Expert#3(diabeticeducator)viewedtheshynessfromtakingmedicationortestingbloodglucose

inpublic,andtheimageofdiabetesinsocietyasaproblemthatfacesdoctorsanddiabetic

educators.Theexpertsaidthatevenwhentheysetupgroupmeetingaboutself-management

mostofthepatientsrefusetoattenditbecausetheypreferonetoonemeetingtokeeptheir

privacy.Furthermore,theexpertexpressedherworriesthatsomepatientsmightnotwantto

communicateonlineaswell,becauseasshesaidsomeofthemdonotwanttotalkabouttheir

illness.

Overall

Ingeneral,thefindingsoftheinterviewsshowaconsensusfromboththemedicalexpertsandthe

game/gamificationexpertsontheimportanceoftheconceptsthatcomposetheframework.The

gamesandgamificationexpertswereshowntheframeworkandtheyindicatedthatthe

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frameworkiscomprehensiveandthegamemechanicsareintegratedwiththeotherelements.

Oneoftheexpertsaid:“ithasalltheprinciplesofgamification.Andthecommunityaspectisvery

good.Ithinkgamificationalwaysworkinacommunitybecauseyouareabletosharesomething

youachieved,orsomecomments,orsuggestionsorexperiencesandstories.Ifyouthinkabout

thestoryaspectandthenpeoplegetempathyfromwhattheyhavebeendoing,theyrelate

themselvestoothers,whichcreaterelatedness.SoIthinkithaseverythingintegrated.”

Finally,oneofthepsychiatrist(Expert#3),said,bytheendoftheinterview,thattheframeworkis

comprehensiveandisaverygoodstarttoincreasetheengagementandmotivationofdiabetic

patients.Theexpertsaidthatshebelievesthatitcouldimpactusersespeciallyadolescentand

childrenwithdiabetesmorethantheimpactofthemedicaldoctors.Shealsomentionedthatthis

canbegeneralizedtootherillnessesthatneedself-management.However,shesaidthatthe

frameworkneedstobeimplementedinanapplicationandstudiedwithasmallgroupofpeople

torevelanydeficitinitandmakemodificationsifneededbeforegeneralizingit.Futureworkis

discussedin(Sec.6.2).

Thefindingsoftheexpertinterviewsvalidatethethemesoftheframework,andthenextstageis

tocross-validatetheframeworkviathequantitativestudy.

4.6 Study2:TheQuestionnaire

Inthissection,thesecondpartofthevalidationoftheframeworkispresented.Thispartconsists

ofthequantitativestudyofthemixedmethodapproachchosenforvalidation.Theobjectiveof

thequestionnaireistomeasuretheacceptanceoftheindividualswithdiabetesbasedinSaudi

Arabiatowardtheconceptsoftheframework.Thesectionisdividedintothreeparts.First,the

questionnairedesignandsamplingarepresented.Then,thequestionnaireprocessisdiscussed.

Finally,thequestionnaireresultsarepresented.

4.6.1 QuestionnaireDesignandProcess

Theself-administeredquestionnaireisthesecondpartofthemethodologicaltriangulationstudy

tovalidatetheframeworkTheWheelofSukr(SeeSec.3.1).Combiningtwoormoremethodsin

theresearchcanenhancetheresultsbyprovidingbetterunderstandingoftheissuefrommultiple

sides(Creswel,2003).Also,methodologicaltriangulationisusedtominimizebiasinthestudy,

andincreasesthevalidityoftheresultsandensuresthatitisnot“amethodologicalartefact”

(Denzin,1978).

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Theaimofthequestionnaireistomeasuretheacceptanceoftheindividualswithdiabetesin

SaudiArabiatowardstheconceptsunderlyingtheframework.Thequestionnairewaschosento

collectdatathisdataasopposedtoothermethodssuchasinterviewsorfocusgroups.As

mentionedinSec.3.1.1.2questionnairesisverycommonchoiceforcollectingduetomany

reasonsincludingtheabilitytocollectlargenumberofdata,itcanbeanalysedobjectively

throughstatisticalmethods,“theabilitytocountfrequencyofoccurrenceofopinionsand

attitudes”,theanonymityfactorcaneliminateanybiasesthatcouldresultinafacetofacestudy

(SomekhandLwein,2005)(SeeSec.3.1.1.3).Furthermore,inthisstudyanonlinequestionnaire

wasthebestchoicetogetdatafromindividualswithdiabetesbasedinSaudiArabia.Thatis

becausehavingonetooneinterviewsorfocusgroupinterviewsisnotfeasibleinthiscasedueto

highstigmaandothergenderbasedculturalreasons.

Thereareseveralmethodstocollectresponsesfromparticipantsinaquestionnairee.g.yesorno,

multiplechoice,andLikertscale.Thelatterisacommonmethodtocollectparticipants’beliefs,

attitudes,andopinions.Inthisapproachparticipantschosebetweennumberofchoicesto

expresstheiragreement,disagreement,orneutralitytoastatement(i.e.thequestion).Onthe

otherhand,indichotomousquestions(i.e.yesorno)theparticipantsarelimitedtotwo

responses.Whilethismethodiseasytoscorefortheuser,itdoesnotprovidetheresearcherwith

enoughinformationtoanalyse.Furthermore,multiple-choicequestionsprovidetheparticipants

withanumberofoptionstochoosefrom.Thistypeofquestionsisgoodtoprovidethe

participantswithspecificanswerstochoosefrom,eachsetofanswersisspecifictothequestion.

Itiseasytoanswerandcouldbeusedtocollectdemographicalinformationontheparticipants.

AcombinationofmultiplechoicequestionsandLikertscalequestionsareusedinthisstudy.Afive

pointLikertscaleisusedinthisstudyasopposedtoa6pointLikertscale.Thisistoallowarange

ofanswersthatcoversarrangeofagreementandaneutralchoice.Also,toavoidaforcedanswer

thatcouldresultoftheuseofanevennumberLikertscale.Theresearcherwantstoleavethe

opportunitytoparticipanttoexpresstheiropinionina5pointLikeretscalethathasa“neutral”

optiontogethonestresponseswithoutpushingthemtoeithersides(agreeordisagree).For

example,somepeoplemightnotfinditimportanttothemtohaveanapplicationwithgood

designtologdata,butatthesametimetheywillnotobjecttoincludingthissotheywillbe

neutral.Havinga“neutral”pointcangivepeopleachancetothosewhodonothaveastrong

opinionabouttheissueathand.

Theself-administeredquestionnaireconsistsoftwoparts:multiple-choicequestionsandLikert-

scalequestions,whichhadfivechoices(stronglyagree,agree,neutral,disagree,andstrongly

disagree),eachweightedfrom5to1respectively.Moreover,aspacewasoffered(i.e.comment

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box)attheendofthequestionnairetoleaveanoptionalcomment.Themultiple-choicequestions

wereaskedinordertogatherinformationfromparticipantsaboutdemographicsandself-

managementhabits.Thepartofthequestionnaireiswheretheinclusionandexclusioncriteria

arespecified.

Thesecondpartofthequestionnaireconsistedof5pointLikertscalethatwasusedtomeasure

theattitudeoftheparticipantstowardtheunderlyingconceptsoftheframeworkthemes.Each

questionhastocaptureanunderlyingconceptintheframeworkandgathertheopinion,attitudes

ofthepatientstowardsit.Thequestionshadtofollowstandardssuchasavoidtheuseofjargon,

itshouldbeeasyandstraightforward,shortaspossible,andnotambiguous(ChoiandPak,2005;

Rowley,2014).

Furthermore,sincethequestionsareaboutthethemesoftheframework,whicharesynthesised

fromliterature,thenthisstudyisadeductiveresearch.Inparticular,thequestionsareinformed

bypreviousresearchintermsofthetypeofthingstobeasked(Rowley,2014).Forexample,the

questionsonthesocializingthemeareinformedbytheliteratureonthepositiveeffectsofweb

2.0andsocialmediaonindividualswithdiabetes(Steinhardtetal.,2009;ShawandJohnson,

2011;HaltiwangerandBrutus,2012;Nacke,KlauserandPrescod,2015),andthefunand

motivationthemesquestionsareinformedbytheliteratureongamificationandusercomments

onexistinggamifiedself-managementapps(e.g.mySugr)(LinandZhu,2012;BunchballInc,2013;

Kingetal.,2013;Rose,KonigandWiesbauer,2013;HamariandKoivisto,2015).

Inparticular,thequestionsweredesignedtocapturetheoverallideaoftheframeworkandits

themesinsteadoffocusingonthetechnicalconceptsoftheelements.Thisisbecause

gamificationmaynotbeafamiliartopictomostparticipants.Toclarify,assumethatthe

researcherwantedtovalidatethebadgeselementoftheFunthemeusingthefollowing

statement:Gettingbadgesonmydiabeticentriesisgoingtomakemeconsistentindoingso.

Sincegamificationisanewconceptandnotmanyapplicationsareusingit,normanyarticles(at

thetimeofthestudy)werewrittenaboutitinArabic,chancesarethattheparticipantwillnot

understandthemeaningofthequestion.Thisisespeciallybecausethestatementisoutof

contextandtherearenoexamplesorpreviousexperiencewithgamificationthattheusercan

buildtheiranswerupon.However,theresearcherchosetopresentthestatementsinawaythat

nomatterwhatknowledgeorexperienceanindividualhadongamificationoranyotherconcept

oftheWheelofSukrhe/shecouldgiveanhonestanswer.So,insteadofusingthewordbadges

theideaofrewardwasused.

Afterdesigningthequestionnaire,itwaspilotedwiththreeresearchersintheareaofgamesand

gamification(withexpertiseinwritingquestionnaires)andsomeofthequestionsweremodified

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afterthat.Thefeedbackfromthemhelpedinsomeofthetechnicaljargonthatwasfoundandto

improvethequestions.Furthermore,thequestionswereplacedrandomlyinthequestionnaire,

andafewquestionswererepeatedindifferentplacestoensurevalidityoftheanswers.Then,the

questionnairewastranslatedintoArabiclanguagebecauseitistargetingindividualswithdiabetes

inSaudiArabia.However,toverifytheaccuracyofthequestionnaireitwasbacktranslatedby

academicswithprofessionaltranslationskills.Moreover,agoodpracticeindesigning

questionnairesistovalidateitwithsampleusers,beforedistributingittotheintendedaudience

(Rogers,SharpandPreece,2011).Thus,theArabicversionofthequestionnairewaspilotedwith

twoindividualswithdiabetesbeforedistributingittothetargetedaudience,andchangeswere

madeaccordingtotheirfeedback.Finally,Cronbach’salphawasappliedtochecktheinternal

consistencyofthequestionnaire(BlandandAltman,1997).Thetestwasappliedtothe

questionnaire,andtheresultwas0.91,whichindicatesaninternalconsistencyofthe

questionnaire.

ThetargetaudienceofthequestionnaireisdiabeticsinSaudiArabia,wherediabetesiswide

spread(3.4millionin2015)andhasahighprevalence(SaudiArabia|InternationalDiabetes

Federation,2015;Choetal.,2015).SaudiArabiaisoneofthetop10countriesfornumberof

childrenwithtype1diabetes—ithas16,200children15yearsoldandyoungerin2015,whichisa

quarteroftheregion’stotalof60,700patients(Choetal.,2015).Theself-administered

questionnairewasdistributedtoasampleofdiabeticpatientsinSaudiArabiathroughsocial

media(TwitterandFacebook).

Table4-6showstheLikertscalepartofthequestionnaire.Eachquestionislinkedtoatheme.The

themesareshownasfollows:Fun(F),Socialising(So),Esteem(E),Self-management(S-M),

Motivation(M),Growth(G),Self-representation(S-R),andSustainability(Su).

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Table4-6Thequestionnaire

Q Question/s

F 1 ItisimportantformewhenIuseanAppfordiabetesthatitisnotboringinits

designandusage.

2 Iprefersocialnetworksaretheonescontainingentertainment(and

encouragements)features.

3 Ifeelsatisfiedwhenmyworkinself-managingmydiabetesisappreciated.

4 IwillworkrelentlesslytoalwayskeeparecordofmytestresultsifIhavethe

opportunitytopositivelycompetewithotherdiabeticpatients.

5 Theavailabilityofdifferenttypesofmotivatorsinthediabeticsocialnetworkswill

encouragemetopromptlyrecordmytests.

S 6 Iliketosharemypositiveresultswithothers

7 Iprefertointeractwithdiabeticpatientsthroughtheinternetbutnotinreallife.

8 Iwouldliketomakefriendshipswithdiabeticpatients.

9 Communicatingwithdiabeticfriendsishelpingmecopewithdiabetes.

10 Socialnetworksishelpingmecopewithdiabetes.

11 Beingpartofadiabetic-orientedsocialnetworkwillhelpmetolivepositivelywith

diabetes.

12 ThesocialsupportthatIreceivefromtheInternetisimportanttome.

13 Itisdifficultformynon-diabeticfriendstounderstandandappreciatemysituation.

14 Iwouldliketoparticipateinasocialnetworkthatenablesmetocommunicatewith

diabeticpatients.

E 15 Iwillbemoreencouragedtoself-managemydiabetesifIseeotherpatients'

records\progress.

16 Iwouldliketosharemydiabetestestswithotherdiabeticfriends,especiallythe

positiveresults.

17 IwillbemotivatedtosupportothersifIparticipateinasocialnetworkfordiabetes.

S- 18 Ionlyrecordmyteststoshowthemtomydoctor

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M 19 Aself-managementsystemfordiabetesisbeneficialifitprovidesfeedbacktothe

usersbasedontheirdailyentries.

M 20 Ilackself-motivationtokeeparecordandfollowupmysituationinadailybasis.

21 Iamwellawareoftheimportanceofmyroleinmanagingmydiabetes.

22 Iwouldliketoself-managemyconditionasbestaspossiblealongwithkeepingmy

routinelymeetingswiththedoctor.

G 23 IwouldliketoreceivenotificationseverytimeIrecordmytestresults,andforthem

tobecomparedtomyprevioustests.

24 Iwouldliketobenotifiedwithmyglucoselevelfluctuatesabnormally.

25 Myunderstandingofhowtoself-managemysituationmakesmefeelsecureand

content.

26 Itisimportanttometocontrolmyhealththroughimprovingmyself-management

skills.

27 WhenIuseanewApp,itisimportantformethatithelpsmeachievemygoalsthat

arerelatedtomysituation.(E.g.achievingacertainlevelofglucose,orburninga

certainnumberofcalories.)

S-R 28 IwouldlikemyvirtualaccountontheInternet(profile,photo,etc.)toreflectmy

personality.

29 IdonotuseArabicAppsfordiabetes(mobileorcomputer)becauseoftheirbad

designandquality.

30 DiabetesisnegativelylookedatinSaudiArabia

Su 31 WhenusingadiabetesmanagementApp,itisimportantthatitisregularly

updated.

32 Ineedtobeencouragedinordertokeeprecordingmytestonadailybasis.

33 Ifeelboredwhenusinganappforseveraltimes.

34 IenjoybeingchallengedatalevelthatsuitsmewhenIplayinmymobileor

computer.

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4.6.1.1 QuestionnaireSample

Inquantitativemethods,statisticalvalidityissought.Thus,thesizeofthesamplemustbe

determinedpriortodistributingthequestionnaire.Asampleischosenfromalarger

measurementthatisapopulation(Mendenhall,BeaverandBeaver,2012).Inthiscase,the

populationistheallthediabeticpeopleinSaudiArabia.However,itisnotpossibletostudyallthe

population,soasampleischosenasarepresentativeofthepopulation.Thisdescribesthe

behaviourofthepopulationonthebasisoftheinformationobtainedfromtherepresentative

samplefromthatpopulation.

Furthermore,samplescanbeselectedbytwomethods,eitherprobability(simplerandom,

systematicrandom,stratified,multi-stagecluster)ornon-probability(Convenience,Snowball,

Quota,Theoretical)(Bernard,2006).Inthisstudy,thesnowballmethodwasusedtoselectthe

sampleforthepatients’questionnaire.

Priortothedistributionofthequestionnaire,thesamplesizewasestimatedbypoweranalysis

usingtheprogramG*power[Table4-7].Followingtheconvention,settingα=.05,β=0.2,andthe

effectsizedischosentobelarge(setto0.8)toensurethatthemeansofthedatasignificantly

deviatefromthemeanoftheweights(Cohen,1988).Basedonthis,theminimumsamplesizeis

15.

However,afterdistributingthequestionnaire,42individualscompletedit,whichislargerthanthe

minimumsamplesizecalculatedbypoweranalysis.Additionally,thisnumbersuggestthatwecan

uset-testsonthissamplebecauseaccordingtothecentrallimittheoremthetdistributionofa

samplelargerthan30isclosetoanormaldistributionregardlessofthedistributionofthedata.

Table4-7G*PowerValues

Effectsized 0.8(large)

αtype1error 0.05

Power(1-β) 0.8

MinimumSampleSize 15

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4.6.1.2 QuestionnaireProcess

ThedatawascollectedviatheonlinetoolSurveyMonkey31.Thequestionnairewasdistributed

usingsocialmediaoutlets(i.e.TwitterandFacebook).Anumberofsocialmediagroupsfor

diabetespatientswereidentifiedandwereaskedtosharethequestionnaire.Aninclusionand

exclusionmethodwasusedintermsofdemographicalquestionswheretheparticipantshadtobe

diabetics,ranginginagebetween18and40.

Followingtheethicalrequirements,thefirstpageofthequestionnairepresentsaparticipant’s

informationsheet.Thisincludestheaimofthequestionnaireandthetargetaudience(i.e.

individualswithdiabetes).Moreover,itwasdeclaredthattheparticipantswouldbeanonymous

andthatnopersonaldatawouldbecollected.Inaddition,itwasmentionedthattheir

participationwasvoluntaryandthattheycouldwithdrawatanytimewithoutconsequences.

Thosewhochoosetoparticipateinthestudywerepresentedwiththefirstpartofthe

questionnaire,whichincludedthesixgeneralanddemographicalquestions[Table4-8].After

answeringthesequestions,theparticipantswerepresentedwiththesecondpartofthe

questionnairewhichcontainsthirty-fourquestionsonthethemesofTheWheelofSukr.

Thequestionnairewasdesignedinawaythatreflectstheideasofthethemeswithoutusing

jargonorconfusingtheuser.Itwasnotassumedthatuserswerefamiliarwithgamificationor

gamesusedfortheself-managementofdiabetes,astherearenogamificationappsforthisinthe

SaudiArabia.

4.6.1.3 DataAnalysis

Demographicdata:

Thedatafromeachquestionfromthefirstpartofthequestionnairewassubjectedtoa

descriptiveanalysiswherebythefrequenciesofresponseswereobtained.Frequenciesarethe

numberoftimesacertainanswerhasappeared.Thisgivesinsightintopossibleclusteringforone

ofthevariables.Forexample,itcouldshowthatthemajorityarearoundacertainageorofa

certaingenderandsoforth.Twocommonwaystoshowfrequenciesarepiechartsand

histograms.

Likertscaledata:

31https://www.surveymonkey.co.uk/

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ALikertscalecanbeanalysedbydifferentstatisticaltests.Thegoalofthesetestsistocheckthe

differenceofastatisticalquantityofasample(suchasthemeanormedian)againstaconstant

mean.Performingallofthesestatisticaltestscanbecarriedoutthroughanumberofwell-known

programssuchasSPSS,whichisuser-friendlyasithasagraphicalinterfaceandthestatistical

analysisisreadilyavailablethroughanumberoffunctions.

T-testsarethemostcommontestusedforLikertscaleanalysissincethestandarddeviationofthe

populationisusuallyunknown.Inordertoapplythet-testitisusuallyimportanttocheckthe

followingassumptions.First,thedatashouldberandomlyselected.Second,thedatashouldcome

fromapopulationthatisnormallydistributed.However,itisknownthatthet-testisnotsubject

tosignificantchangeswhenthesecondassumptionisviolated,especiallyifthesizeofthesample

islargeenough(Mendenhall,BeaverandBeaver,2006).

Thus,toanalysethedataoftheLikertscaleinthisstudyaone-samplet-test(2tailed)is

performed.Thet-testcanbeusedonthissamplefollowingthecentrallimittheoremrule(as

discussedinSec.0).Theaimofthetestistocheckwhetherthemeanoftheanswersforeach

iteminthequestionnairediffersfrom3withstatisticalsignificance.

Thefollowinghypotheseswereusedforeachquestion:

H0(nullhypothesis):mean=3

H1(alternativehypothesis):mean≠3

Torejectthenullhypothesis,thePvaluemustbeP<α(type1error).Sincethequestionnaire

contains34questions,theBonferronicorrectionwasused(BlandandAltman,1995).Specifically,

αiscorrectedtobe.05/34=.0014705.Hence,thePvalueforeachquestionshouldbelessor

equaltothenewcorrectedvalueforthenullhypothesistoberejected.However,itisworth

mentioningthattheBonferronicorrectioncanbetooconservative.

4.6.2 QuestionnaireResults

Inthissection,theresultsfromtheanalysisofthequestionnairearepresentedanddiscussed.The

sectionisdividedintotwopartsbasedonthequestionnaire.Thefirstpartdiscussesthe

demographicalandmultiple-choicegeneralquestionsinthequestionnaire,andthesecondpart

discussestheresultsofthefrequencytestandstatisticalanalysisoftheLikertscalequestions.

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4.6.2.1 PartoneoftheQuestionnaire

Table4-8showstheresultsofPart1ofthequestionnaire,whichcontainedmultiple-choice

questionsondemographicalquestionsandhabitsrelatedtotheirself-management.

Figure4-5ParticipantsAgeGroup

45.24%oftheparticipantswerediagnosedwithdiabetes9+yearsago.Theparticipantswere

fromdifferentagegroups[Figure4-5].45%ofparticipantssearchfordiabetesontheInternetin

bothEnglishandArabic,while33%searchonlyinArabicand16%donotusetheInternettoget

informationondiabetes.Also,mostoftheparticipantshavediabeticfriends(71%).Furthermore,

59.52%ofparticipantsdonotrecordtheirbloodglucoseonadailybasis.Whentheydokeepa

record,66.67%usemanuallogbookstorecordtheirdata(penandpaper).

4.6.2.2 ParttwooftheQuestionnaire

Table4-9showstheresultsofthesecondpartofthequestionnaire,whichcontainedLikert-scale

questionsonthethemesoftheframework.Eachthemewasassociatedwithanumberof

questionstomeasuretheattitudetowardsthethemeasshowninthetable.

Thefuntheme,forexample,hasfivequestionsrelatedtoit.ThefrequenciesforeachLikert-scale

item(e.g.stronglyagree)wereaveraged.ThisresultisshowninthefirstcolumninTable3

(39.05%).Inaddition,thesumofthe“stronglyagree”and“agree”answersisshowninthe“fun”

row(75.71%).Similarly,thesumofthe“disagree”and“stronglydisagree”isshown.Thesame

procedurewasdoneforallthequestions.

Table4-10showsthemeanandPvalueofthequestionsasked.

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Table4-8DatafromPart1oftheQuestionnaire

Question/answerchoice Responses

Agegroup

18-20yearsold 21.43%

21-25yearsold 30.95%

26-30yearsold 11.90%

31-35yearsold 14.29%

36-40yearsold 21.43%

Gender

Female 76.19%

Male 23.81%

Whenwhereyoudiagnosedwithdiabetes?

0-1years 14.29%

2-4years 26.19%

5-8years 14.29%

9+years 45.24%

Doyouhavefriendswithdiabetes?

Yes 71.43%

No 28.57%

Doyoukeepalogofallyourdailytestresults?

Yes 40.48%

No 59.52%

Howdoyoulogyourdailytestresults?

Manually(usingapenandpaper) 66.67%

Electronically(usingmobileapps,orcomputersystems,etc) 33.33%

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Table4-9FrequencyTable

Strongly

AgreeAgree Neutral Disagree

Strongly

Disagree

Fun

39.05% 36.67%

19.52%

3.81% 0.95% 100.00%

75.71% 4.76%

Social

33.86% 34.13%

18.78%

11.64% 1.59% 100.00%

67.99% 13.23%

Esteem

34.92% 44.44%

11.11%

8.73% 0.79% 100.00%

79.37% 9.52%

Self-

management

23.81% 48.81%

13.10%

11.90% 2.38% 100.00%

72.62% 14.29%

Motivation

38.89% 38.10%

11.90%

8.73% 2.38% 100.00%

76.98% 11.11%

Growth

43.33% 44.76%

8.57%

2.86% 0.48% 100.00%

88.10% 3.33%

Self-

representation

19.05% 23.81%

36.51%

19.05% 1.59% 100.00%

42.86% 20.63%

Sustainability

27.38% 41.07%

20.83%

10.71% 0.00% 100.00%

68.45% 10.71%

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Table4-10TheStatisticalAnalysisoftheQuestionnaire(SPSS)

QuestionNumber Mean P-Value(2-tailed)

1 4.33 <0.001

2 3.95 <0.001

3 4.50 <0.001

4 3.76 <0.001

5 3.90 <0.001

6 3.76 <0.001

7 3.07 .667

8 4.12 <0.001

9 4.14 <0.001

10 4.02 <0.001

11 4.05 <0.001

12 4.10 <0.001

13 3.40 .058

14 4.17 <0.001

15 3.95 <0.001

16 3.79 <0.001

17 4.38 <0.001

18 3.40 .030

19 4.19 <0.001

20 3.24 .215

21 4.55 <0.001

22 4.29 <0.001

23 3.76 <0.001

24 4.48 <0.001

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25 4.43 <0.001

26 4.40 <0.001

27 4.31 <0.001

28 3.71 <0.001

29 3.14 .279

30 3.33 .070

31 4.24 <0.001

32 4.07 <0.001

33 3.17 .255

34 3.93 <0.001

TheFunTheme

Overall,whenweaveragethefrequenciesoftheanswerstoeachLikertitemwefindthat32/42

(76%)respondedbystronglyagreeoragree,8/42(19%)wereneutral,and2/42(5%)strongly

disagreedordisagreed.Thissuggeststhatthemajorityoftheparticipantssupporttheimportance

ofthefuntheme.Sinceithelpsthemovercomeanyboredomfromtherepetitivetasksand

provideentertainmentandencouragement.Italsogivesthemtheopportunitytobeappreciated

fortheireffortsinself-management,andtheopportunitytopositivelycompetewithoneanother.

Morespecifically,itisworthmentioningthatwhenindividualswithdiabeteswereasked:

Q1:itisimportantformewhenIuseanappfordiabetesthatitisnotboringinitsdesign

andusage.

Q2:Iprefersocialnetworksaretheonescontainingentertainmentfeatures.

47.62%oftheparticipantsstronglyagreedwiththestatementofQ1,themeanoftheanswersto

thisquestionis4.33(P<<0.001).Inaddition,whenaskedaboutusingentertainmentfeaturesina

socialcontext,participantsagreedtothisstatement(Q2)asindicatedbyameanof3.95(P<<

0.001).Thissuggeststhatanentertainingandenjoyableexperienceinusingaself-management

appcanbeofinteresttotheusers.

Moreover,whentheparticipantswereasked:

Q3:Ifeelsatisfiedwhenmyworkinself-managingmydiabetesisappreciated

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59.52%ofthemstronglyagreedwiththisstatement,andthemeanoftheanswersofthis

questionwas4.50(P<<0.001)suggestingthattheuseofarewardsystemtoencouragethemand

acknowledgetheirself-managementeffortsisimportantandcouldhaveapositiveeffecton

them.

TheSocialisingTheme

Followingthesameprocedureasdescribedinthefuntheme,28/42(68%)oftheparticipants

answeredwithstronglyagreeoragree,8/42(19%)wereneutral,and5/42(13%)supported

stronglydisagreeordisagree.Thissuggeststhatdiabeticslikesharingtheirpositiveresultswith

oneanother,andestablishingnewfriendshipswiththeirpeers.Thiscouldhelpthemcopeand

livepositivelywiththeircondition.

Particularly,whenparticipantswereasked:

Q6:Iliketosharemypositiveresultswithothers

Q8:Iwouldliketomakefriendshipswithdiabeticpatients.

Q9:communicatingwithdiabeticfriendswillhelpmecopewithdiabetes

ThemeanoftheanswersofQ6was3.79withP<<0.001,andthemeanoftheanswersofQ8was

4.12withP<<0.001,thiscouldindicatethatthesocialaspectespeciallymakingconnectionswith

otherindividualswithdiabetesandsharingwiththempositiveresultswouldbeappreciatedby

theuser.ThiscanalsohelpindividualswithdiabetescopewiththeirillnessesassupportedbyQ9

(mean=4.14,P<<0.001).

TheEsteemTheme

TheresultsoftheaveragedfrequenciesoftheanswerstotheLikertscaleareasfollows:33/42

(79%)stronglyagreeoragree,5/42(11%)neutral,and4/42(9%)stronglydisagreeordisagree.

Clearly,themajorityoftheparticipantssupportedthistheme.Itisworthrecallingthattheesteem

themeincludesprogressbars,leaderboards,andreputation.So,byenablingthepatientstosee

eachother’sscoresandprogresstheywillbeencouragedtoself-manage.Moreimportantly,the

patientswillhavethechancetosupportandencourageeachother.

Specifically,whenaskedabout:

Q15:Iwillbemoreencouragedtoself-managemydiabetesifIseeotherpatients’

record/progress.

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ThemeanoftheanswersforQ15was3.95withP<<0.001.Thisindicatesthattheuseof

leaderboardsandprogressbarcanbeeffectiveinmotivatinguserstoself-manage,whichisalso

relatedtootherthemessuchassocialisingandfunthemes.

TheSelf-ManagementTheme

Participantswhostronglyagreedoragreedwere31/42(73%),5/42(13%)wereneutral,and6/42

(14%)stronglydisagreedordisagreed.Inparticular,themajorityofparticipantsseethatthata

self-managementsystemshouldprovideinformation,tips,andnotification.Moreover,when

participantswereaskedabout:

Q18:Ionlyrecordmyteststoshowthemtomydoctor

24/42(57%)agreedorstronglyagreedwiththisstatement,withthemean=3.40andP=0.03.

Thiscouldsignifyaneedfordevelopingbetterself-managementhabits.

TheMotivationTheme

Theoverallresultsofparticipantswhostronglyagreedoragreedwere32/42(76%),5/42(12%)

wereneutral,and5/42(12%)stronglydisagreedordisagreed.Theparticipantssupportedthe

relevanceofthemotivationtheme.Theresultindicatesthattheparticipantsrecognizetheirrole

inmanagingtheircondition,andtheyarekeentokeeptheirillnessincontrol.

Morespecifically,whenparticipantswereasked:

Q22:Iwouldliketoself-managemyconditionasbestaspossiblealongwithkeepingmy

routinelymeetingwiththedoctor.

Themeanoftheanswersis4.29withP<<0.001,whichsuggestthatparticipantsarewantsto

bettertheirself-managementskillsandbyusingexternalmotivatorsandenhancingtheirinternal

motivationtheycanachievethis.

TheGrowthTheme

37/42(88%)oftheparticipantsansweredagreeorstronglyagree,while1/42(3%)answered

disagreeorstronglydisagree.Thisthemereceivedmuchsupportfromtheparticipants.Recallthat

thegrowththemecombinesfeedback,achievinggoalsandtinyhabits.Theparticipantsagreed

thatreceivingfeedbackregardinginputs(glucoselevels,foodintake,etc)isimportantsincethis

enablesthemtoself-managetheircondition.

Particularly,whenparticipantswereasked,

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Q25:myunderstandingofhowtoself-managemysituationmakesmefeelsecureand

content.

Q26:Itisimportanttometocontrolmyhealththroughimprovingmyself-management

skills.

BothQ25andQ26hadmeansofanswers4.43and4.40,andPvalues<<0.001,respectively.This

indicatesuserscouldbenefitfromtheuseofself-managementappsthathelpthemingrowingin

termsoftheirself-managementskills.Theuseofotherelementssuchvisualisationofdatafrom

theself-managementthemecouldhelpthemindoingso.

TheSelf-RepresentationTheme

Participantswhoagreedandstronglyagreedwere18/42(43%),15/42(36%)wereneutral,and

9/42(21%)disagreedorstronglydisagreed.Ifweconsiderquestion27(Itisimportanttometo

keepaneyeonmyhealththoughimprovingmyself-managementskills)only,then23/42(55%)

agreeorstronglyagree,while6/42(14%)disagree.Thisindicatesthatonlineself-representation

isimportanttoasignificantnumberoftheparticipants,whichsuggeststhattheself-

representationthemeisindeedrelevant.

Whentheparticipantswereasked:

Q28:Iwouldlikemyvirtualaccountontheinternet(profile,photo,etc.)toreflectmy

personality.

Themeanoftheanswersis3.71withp<<0.001,whichindicatethesignificanceof

personalisationoftheuserexperienceinusingtheapp.

TheSustainabilityTheme

Theresultsshowedthat28/42(68%)agreedorstronglyagreed,9/42(21%)wereneutral,and

5/42(11%)disagreedorstronglydisagreed.Aconsiderablylargenumberofparticipantsagreed

thatself-managementappsshouldberegularlyupdated.Theseupdatesshouldkeepthem

encouragedtokeepusingtheapp,forinstance,byaddingmorelevelsorchallengesthatkeepthe

patientsmotivatedtousetheapp,andthereforecontinueself-managingtheirconditionina

sustainablemanner.Also,theresultsshowthatpeopleneedtobetriggeredandmotivatedinto

usinganelectroniclogbookonadailybasis.

Inparticular,whenasked:

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Q31:whenusingadiabetesmanagementapp,itisimportantthatitisregularly

updated.

Q34:IenjoybeingchallengedatalevelthatsuitsmewhenIplayinmymobileor

computer.

ThemeanoftheanswersforQ31is4.07(P<<0.001),andthemeanofanswersforQ34is3.93

(P<<0.001).Thissuggestthattheusersfindtoolsthatarenotupdatedregularlyareuseless.

Moreover,thattheflowtheoryisanimportantaspectofthecontinuityofanactivity.Insuch,

whenthelevelofdifficultyofagameisalignedtothelevelofexperiencetheuserisgaining.Thus,

iftheexperienceisstatictheuserwillgetbored,aswellaswhenthelevelofdifficultydoesnot

increasewiththeuser’sabilities.

FurtherAnalysis:

Intheprevioussectionwediscussedthestatisticalanalysisofthequestionnaireintermsofthe

themes.Inthissectionweanalysethequestionsintermsofcontextandhighlightany

relationshipsorcontradictions.Itisworthmentioningthattherelationshipbetweenthe

demographicalinformationandtheanswerswerecheckedandnostatisticalsignificancewas

foundforalmostallofthequestions.Thedatawascheckedusinga2-tailed,2samplet-testto

checkifthemeanstoeachanswerdifferbasedonthedemographicaldata.However,questions

22,20,18,30,29,13,33and34havesomeinterestingobservationswhicharediscussedinthis

section.

§ TherelationshipbetweentheanswersofQ22andQ20:

Q22:Iwouldliketoself-managemyconditionasbestaspossiblealongwithkeepingmy

routinelymeetingwiththedoctor.

Q20:Ilackself-motivationtokeeparecordandfollowupmysituationinadailybasis.

AsdiscussedintheMotivationthemeQ22suggeststhatparticipantswanttobetterself-

managementskills.However,nosignificancewasfoundinQ20wherewehadtokeepthenull

hypothesis.Uponfurtheranalysisofthisquestionandthedemographics,itcanbeseenthat5out

of17ofthosewhorecordtheirtestresultsdailyansweredwithstronglyagreeoragreetoQ20,

while3wereneutraltoQ20.Thisshowsthateventhoughtheyrecorddailytheyfeellikethey

needmoremotivation.Also,morethanhalf(15outof25)ofthosewhodonotrecordtheirtest

resultsdailyansweredwithagreeorstronglyagreetoQ20,while5wereneutralandtheother5

disagreed.Intotalthenumberofthosewhodisagreedorstronglydisagreed(toQ20)was14out

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of42participants,whichislessthanthenumberofthosewhoagreedorstronglyagreedthatthey

lackmotivation(intotal20outof42).Therefore,thedataseemstobeconsistent.

Thedemographicaldataalsoshowedthat11outof28ofthosewhorecordtheirtestresults

manuallydisagreedwithQ20,while5wereneutral,and12agreedorstronglyagreedtolacking

motivation.Ontheotherhand,only3outofthe14whologtheirdataelectronicallydisagreedor

stronglydisagreedtolackingmotivation,3wereneutral,and8outofthe14(morethanhalf)

agreedorstronglyagreed.Clearly,motivationisanissuetoasignificantportionofthe

participants,andthismightbeaddressedbytheWheelofSukranditthemes.

§ TherelationshipbetweentheanswersofQ18andQ20:

Q18:Ionlyrecordmyteststoshowthemtomydoctor

Q20:Ilackself-motivationtokeeparecordandfollowupmysituationinadailybasis.

23outof42participantsansweredagreeorstronglyagreetobothquestions,disagreeorstrongly

disagree,oransweredneutraltobothquestions.Ontheotherhand,8participantsanswered

neutraltooneofthequestionswhileansweringagreeordisagreetotheotherquestions.Finally,

9outof42showedagreementordisagreementtooneofthequestionswhilegivinganopposite

answertotheotherquestion.Specifically,5outof42agreedtoQ18butdisagreedtoQ20.2of

those5donotrecordtheirdataonadailybasiswhiletheother3recordtheirdatadaily.

Moreover,4outof42disagreedtoQ18butagreedtoQ20andallofthemdonotrecordtheir

datadaily.

§ AdetailedanalysisoftheanswersofQ30andthedemographicalquestions:

Q30:DiabetesisnegativelylookedatinSaudiArabia

AsshowninTable4-10,Q30didnothavestatisticalsignificanceandwehadtokeepthenull

hypothesis.However,whenanalysingthisquestionsfurtherwithregardstothedemographical

questionsafewinterestingpointsarise:

• Therewasanagedifferenceintermsofagreementtotheexistingofstigma.12outof22oftheparticipants25yearsoldoryoungeragreedtotheexistenceofstigma,6outof22wereneutral,and4outof22disagreed.Ontheotherhand,participantsolderthan25,9out20participantssaidtheydisagreewithQ30,8agreedorstronglyagreed,and3wereneutral.

• Intermsofyearsofillness(0-4,6outof11disagreedorstronglydisagreed,while8outof11saidtheystronglyagreeoragree)and(5-9+,7outof19saidtheydisagreeorstronglydisagree,while12outof19saidtheyagreeorstronglyagree)

• Usingmanualorelectronictoolstorecordtestshasnocorrelationwiththeanswersregardingstigma.Fromthosewhorecorddataelectronically,9outof28saidtheydisagreewhile5outof28wereneutral,and14outof28agreedorstronglyagreed.From

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thosewhorecordmanually,4outof14disagreed,4outof14wereneutral,and6outof14agreedorstronglyagreed.

§ AdetailedanalysisoftheanswersofQ29andthedemographicalquestions:

Q29:IdonotuseArabicAppsfordiabetes(mobileorcomputer)becauseoftheirbad

designandquality)

Q29didnothavestatisticalsignificancesoitthenullhypothesiswasnotrejected.However,when

analysingthisquestionsfurtherwithregardstothedemographicalquestionsafewinteresting

pointsarise:

• Thosewhorecorddatabyhand:16outof28wereneutral,while7outof28agreedorstronglyagreed,and5outof28disagreedorstronglydisagreed.

• Thosewhorecordtheirtestresultselectronically:8outof14wereneutral,while4outof18agreedorstronglyagreed,and6outod18disagreedorstronglydisagreed.

§ AdetailedanalysisoftheanswersofQ33andthedemographicalquestions:

Q33:Ifeelboredwhenusinganappforseveraltimes.

• 5outof20ofthosewhoareover25yearsoldwereneutral,while5ofthemdisagreedand10outof20agreedorstronglyagreed.

• 9outof22ofthosewhoare25yearsoldoryoungerwereneutral,while7outof22disagreed,and6outof22agreedorstronglyagreed.

• Only1outof14ofthosewhologtheirdataelectronicallydisagreed,6wereneutral,and7outof14agreedorstronglyagreed.

§ AdetailedanalysisoftheanswersofQ13comparedtoQ30andtothedemographicalquestions:

Q13:itisdifficultformynon-diabeticfriendstounderstandandappreciatemysituation.

Q30:DiabetesisnegativelylookedatinSaudiArabia.

Theresultsofbothquestionsdidnothavestatisticalsignificance,andthenullhypothesiswas

accepted.However,uponanalysingthedatafrombothquestionsandcomparingthemwefound

thefollowingpoints:

• 19outof42answeredsimilarlytobothquestions.Specifically,13outof19agreedorstronglyagreedtobothstatements,while1outof19wasneutral,and5outof19disagreed.

Demographicalinformation,specificallytheageoftheparticipantsforQ13:

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• Forthoseabove25yearsold:6outof20disagreedorstronglydisagreed,4outof20wereneutral,and10outof20agreedorstronglyagreed.

• Forthose25andyounger:8outof22disagreedorstronglydisagreed,only2wereneutral,and12agreedorstronglyagreed.

Thisindicatesthatpeersupportisanissueformanyoftheparticipantsanditcanbeaddressedby

theframework.

ParticipantsComments:

Attheendofthequestionnairetherewasa“CommentBox”forparticipantstoleaveoptional

comments.Sixparticipantsleftcomments.Threeofthosewererelatedtothelackofawareness

ondiabetesinthesociety.Asoneofthemsaid:

“Iwishthereismoreawarenessaboutdiabetesinmysociety,andthatpeoplewould

understandthatitisnotcontagiousandthatdiabeticswhotakecareofthemselvescan

copeandliveanormallife.”

Twootherparticipantstalkedaboutthelackofawarenessfromthecommunityandhowitaffects

themnegativelyintermsoftheself-management.thisalsosupportsthedoctors’comments

regardingthenegativeconnotationaroundthediabetesandhowitaffectsthediabeticself-

esteemandtheirself-management.Furthermore,oneofthepatientssaidthatself-management

ofdiabetesenablethemtobepositiveindealingwiththeillness.Anotheronesaidthat“weneed

applicationsforloggingtestresults”,whichindicatethatthereisalackofself-managementapps

inArabic.Finally,onethepatientsmentionedtheirfrustrationthatpeoplearoundthemandtheir

doctorgivetheminstructionwithoutlivingwhatsheisgoingthrough.

4.7 Discussion

Gamificationhasbeenreceivingagreatdealofattentioninthehealthcarefield.InListeretal.

(2014),itwaspointedoutthatthereisalackofprofessionalcriteriaorguidelinestohelp

developersincreatingeffectiveappsutilisinggamificationandbehaviouralchangetheories.In

thischapterwepresentavalidatedframeworkforgamifyingtheself-managementofchronic

illnessestofillagapintheliterature.

Thevalidationwascarriedoutbyamixedmethod,whichincludedexpertinterviewsaswellas

patientquestionnaires.Thecombinationofthecommentsfromtheexpertsandtheresultsfrom

thequestionsvalidatetheframework.Thefindingsoftheinterviewsandresultsofthe

questionnairessupporttheideaofincorporatinggamificationintheself-managementprocessof

diabetes.BothexpertsandpatientsagreedthatutilisingthecombinedthemesoftheWheelof

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Sukrtocreateagamifiedself-managementtoolmighthelpachieveeffectiveself-management

andbehaviouralchange.ToourknowledgetheWheelofSukristhefirstofitskind.

Self-managementofchronicillnesses,especiallyindiabetes,canbeturnedintoanengagingand

enjoyableexperiencebytheuseofgamification.Theresultsofthisstudysupportthisnotion,and

indicatethatbothexpertsanddiabeticpatientsrecognizethepotentialofgamificationin

improvingself-managementofdiabetessignificantly.Inparticular,expertshighlightedthe

importanceofrewards,competition,andotherfunelementsincreatinganenjoyableand

rewardingexperiencethatcouldleadtopositivebehaviouralchange.This,inturn,isreinforcedby

thefindingsfromthepatientquestionnaireasshownintheResultssection.

Theresultsofbothstudiesalsoindicatedthatthereisanissuewithengagementwithapplications

andtheself-managementprocess.AnswerstoQ33showthat7outofthe14participantswholog

theirdataelectronicallyfeelboredwhentheyuseanappseveraltimes.Thisissuecanbe

addressedbytheWheelofSukrframeworkandespeciallythatittakessustainabilityintoaccount.

Indeed,thefindingsoftheexperts’interviewssuggestedthattheuseofelementssuchas

autonomyandpurpose(fromtheself-representationthemes)canenhancethesenseofcontrolin

theuserandincreasetheirengagement.Also,therewardingandengagingaspectofgamification

canbeenhancedbythesustainabilitythemeelementsuchastheusestorylineandthemeswhere

theusercanconnectwiththeappandhaveapleasurableexperience.

Diabetesisalonelyillnessanddiabeticsaremorepronetodepression(Egede,Zhengand

Simpson,2002).AsstatedinSec.2.3.1,beingpartofanonlinecommunitycouldprovidepatients

withtheemotionalandpsychologicalsupporttheyneed.Thisisconfirmedbytheresultsofthe

interviewsandthequestionnaire.Inparticular,expertsemphasisedthepositiveimpactofsocial

mediaandpeersupportonpatients.Furthermore,asoneofthemedicalexpertmentionedthat

thecommunitymustbediabeticonly.ThispointisfulfilledintheWheelofSukrframeworksince

itisfortheself-managementofdiabetesandnotageneralcommunity.Additionally,theresultsof

thequestionnaireindicatethatpatientswouldliketosharepositiveresultswiththeirpeersand

establishfriendshipswiththem.Thiscanhelpthemovercomeanynegativefeelingstheymight

encounter.Thisalsoaccordswiththefindingsfromthemedicalexpertsasoneofthem

mentionedthatprovidingacommunityforpatientscanenablethemtosupportandeducateeach

other.Furthermore,thecommunityaspectofagamifiedself-managementtoolcouldenhance

thevalueofrewardsandotherelementsoftheframework.Thisismanifestedinastatementby

oneofthegamificationexpertswhomentionedthatthecommunityaspectisthemostimportant

partintermsofintegratingalltheotherelementsespeciallythegamificationelements.

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Indeed,thesocializingthemereceivedagreatdealofsupportfromtheexpertsandthepatients.

Particularly,thepeersupportelementwhichaccordingtothemedicalexpertsessentialto

individualswithchronicillness.ThisisalsosupportedbytheliteratureasshowninSec.#.#.#.

Furthermore,theinterviewsfindingsshowtheimportanceofonlinecommunitytopatients

becausepeerscaninfluenceeachother,shareexperiencesandlearnmoreabouttheirillnessina

privateenvironment.Thesocializingthemeisalsoimportantingamificationasindicatedbythe

gamifcationexpertsandthegamificationliterature(seesec.2.3.2).Specifically,thecommunity

aspectintegratesallthethemesoftheframework,andaddstothevalueofthegamification

elementssuchasrewardsandcompetitions.Moreover,theanalysisofQ13showedthat22ofthe

participantsagreedorstronglyagreedthattheirfriendsdonotunderstandtheirsituation.Also,

oneoftheparticipantsexpressedfrustrationthatfriendsandfamilyandevendoctorsdonot

understandherexperiencewiththeillnessanddailyself-management.Thisshowsthatpeer

supportcouldbeanissueformanyofparticipantsanditcanbeaddressedbytheframework.

Additionally,regardingthestigma,theresultsofthequestionnaireshowthatnotallthepatients

agreethatthereisanegativeviewondiabeteseventhoughthedoctorsstressedthispointclearly

intheinterview.Inanycase,20outof42(almosthalfoftheparticipants)agreedthatthereisa

stigmaand9wereneutral(Q30).Since,thisissueisveryimportantforpatientswhohavetodeal

withsuchsituationsareinneedforpeersupportandpeoplewhocanunderstandtheirsituation.

Asoneofthepatientsmentionedinhercommentsthatwasdiscussedintheresultsection(see

sec.4.6.2).Therefore,itisessentialforanapplicationthatapproachgamificaitonandself-

managementholisticallytoenablepeersupport.Indeed,thisalsoaccordswithwhatoneofthe

doctorssaid,thatindividualswithdiabetescanhaveastrongerimpactoneachotherandeducate

eachothermorethanthatofamedicaldoctor.

Moreover,theresultssupportthenotionthatcreatingafunandenjoyableexperiencefor

diabeticpatientscouldhelptheirself-esteem.Inparticular,theinterviewsindicatethatpatient’s

self-esteemhasaneffectonself-management,asoneexpertstated:

“Howthepatientfeelsaboutdiabeteshasagreateffectontheirself-management”

Additionally,theuseofleaderboardsandcreatingfriendlycompetitionbetweenpeerscouldhelp

inboostinguser’sself-esteem.Whilesomeusersmightfindleaderboardsdemotivating

(Nicholson,2015),othersfindleaderboardsandbeingrecognizedinthecommunitymotivating.In

fact,HamariandKoivisto(2015),investigatedtheeffectsofbeinginacommunityandgetting

recognizedbyotherusersforwhatyoudoinagamifiedserviceforexercise.Theymeasuredhow

thesocialinfluenceaffecttheengagementoftheuserwiththegamifiedserviceandthe

maintenanceoftheexercisesupportedbytheservice.Thestudyshowedthatthesocialinfluence

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andbeingrecognizedinthecommunity(whichisachievedingamificationbyleaderboards)can

increaseusers’motivationandengagementwiththeexerciseactivities,andthatthemorefriends

theuserhaveinthegamifiedservicethestrongertheinfluence.Furthermore,theuseofgamified

applicationsthatincludesleaderboardshaseitherpositiveorpartiallypositiveeffectonusers(see

(AppendixA)inHamarietal(2013)).However,leaderboardsshouldnotbecompulsory(tobe

viewed)onalloftheusers,butrathertheyshouldbeaskedoptionallyasisdoneinmanygames

andgamifiedapps.Theesteemthemeanditselementsarealsosupportedbythemajorityof

participantsinthequestionnaire.Thisisbecauseitenablesthemtotracktheirprogress

(individually)andhavetheoptiontocompareittoothers.Alsoitcouldtriggerpositive

competitionbetweenpeersinafriendly,non-judgmentalenvironment.Thisissupportedbythe

patientsanswerstoQ4,Q6,Q15,andQ16.

In2013,astudypointedoutthataround73%ofdiabeticsdonotdocumenttheirdailyglucose

tests(Rose,Koenig,andWeisbauer,2013).Ourresultsagreewiththoseresultssince,ingeneral,

patientsadmittedthattheyonlyrecordtheirtestresultsfortheirdoctorstosee.Infact,almost

75%oftheparticipantsonlyrecordtheirdatatoshowittotheirdoctors.Moreover,accordingto

thedemographicaldatainthequestionnaire,almost60%donotkeepalogbookoftheirdailytest

results.Thisaccordswiththefindingsoftheexperts’interviews,wheremedicaldoctorssaidthat

theirpatientsdonotkeepadailylogbookoftheirresults.Thiscouldbebecausethepatientsare

notawareoftheimportanceofself-managementortheyfindtheself-managementprocess

mundane,whichweresuggestedbythemedicalexperts.Theresultsofboththeinterviewsand

thequestionnairessuggestthatagamifiedself-managementsystemmighthelpthemdocument

daily.Therefore,gamificationinself-managementisexpectedtomaketheself-management

experiencelessmundane.

Theresultsofthequestionnaireshowthat20out42agreedorstronglyagreedthattheylack

motivationtoself-managetheirillness(Q20),whichaccordstothefindingsofthemedicalexperts

interviews.Thesepeoplewholackself-motivationneedtobeencouragedandmotivatedtoself-

managetheirillnessesandtheframeworkcontainsthemesthathavetheopportunitytoaddress

thisissue.Thisincludestheuseofbothintrinsicandextrinsicmotivators,whichwassupportedby

theexperts.Asoneofthegamesandgamificationexpertsaidthatitisimportanttoconsiderboth

typesofmotivation,becauseextrinsiccangrabtheattentionoftheuserbutcouldbeshortterm

andintrinsicmotivationislongerlasting.Also,themedicalexpertsexpressedtheimportanceof

motivationtotheself-managementprocess.Furthermore,peoplewhoareintrinsicallymotivated

canbenefitfromtheexternalmotivationpartoftheframework.

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Furthermore,theresultsshowthatpatientsarewillingtolearnmoreabouttheirconditionand

managethemselvesbetter.However,thiscouldbepreventedbytheshortageofwell-constructed

self-managementtools(especiallyinSaudiArabiawherethepatientsarefrom).Thisissupported

bythefindingsoftheexpertinterviewsthatindicatedthatmanypatientsarenotmotivatedto

learnorself-manage.Gamifyingself-managementcouldincreasepatients’motivation.Yet,many

existinggamifiedapplicationsandservicesfocusonlyonextrinsicmotivation(SeabornandFels,

2014).However,extrinsicmotivationsolelydoesnotcreateasustainablegamificationaffect.The

WheelofSukrconsidersbothtypesofmotivation(intrinsicandextrinsic).Thisallowsittoaddress

someoftheissuesraisedbytheexpertsandenablesittosatisfythepatients’expectations.

Providingreal-timefeedbackthatismeaningfulandrelevanttousersisanessentialpartof

gamification.Thefeedbackcancomeinmanyformsincludingrewardsandgraphsofbloodtests.

Thelatterwillhelpuserslearnmoreabouttheirconditionandrecognizepatterns.Thisis

supportedbythemajorityofparticipantsinthequestionnairewhomentionedthattheywould

liketoreceivefeedbackregardingtheirself-managingprogressandbenotifiedwhentheirblood

glucosefluctuates.Additionally,theimportanceofbeingrepresentedandbeingautonomous

werehighlightedbytheresultsoftheexpertinterviews.Participantsinthequestionnairealso

supportedthis.Agreatdealofthemstressedthattheywouldliketheirvirtualaccountstoreflect

theirpersonality,whichisanintegralpartoftheWheelofSukr.

Furthermore,themedicalexpertstalkedabouttwoissuesregardingdiabetes,thelackof

educationamongstsomeoftheirpatientsandthelackofawarenessinthecommunity.Thispoint

couldexplainthereasonwhy2oftheparticipantsinthequestionnaireagreedthattheyonly

recordtheirdatatoshowthemtotheirdoctors(Q18),butdisagreedthattheylackmotivationto

self-manage(Q20).Also,thedemographicalinformationshowsthatbothparticipantsdonot

recordtheirtestresultsdaily.Moreover,medicalexpertsandtwooftheparticipantsinthe

questionnairediscussedthelackofawarenessaboutdiabetesinthesociety.Theexperts

mentionedthatthisissuecouldnegativelyinfluencetheself-managementprocessofindividuals

withdiabetes.Indeed,thisaccordstothecommentofoneoftheparticipants(seesec.4.6.2).

Whiletheissuesofeducationandawarenessareimportant,itfallsoutsidethescopeofthe

framework,whichisconcernedwiththeuseofgamificationinincreasingengagementand

motivationtotheself-managementprocess.

Allinall,theresultsofthequestionnaireandinterviewscombinedsupportsallthethemesofthe

framework.Therewasnothingintheanalysisthatsuggestshierarchyorimportanceofonetheme

overtheother.Thus,theequalimportanceassumptionisstillvalid.Thisassumptioncanonlybe

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testedinalongitudinalstudywhereanapplicationthatusestheframeworkcollectsdatafrom

individualwithdiabetesorotherchronicillnesses.

Thecorrelationbetweengamificationandhealthbehaviourtheorieshasbeendiscussed(Lister,

West,Cannon,SaxandBordegard,2014).Itwasmentionedthateventhoughgamificationapps

forhealthandfitnessareusingmotivationfromthehealthbehaviourtheory,theuseofcapacity

ortriggersisignored.Patientsmentionedtheimportanceofkeepingappsupdatedtosustain

theirinterestinusingthem.Theyalsonotedtheneedtobeencouragedtokeeprecordingdaily.

Thiscanbedonethroughusingtriggers,whichareanessentialpartoftheframework.Moreover,

patientsstatedthattheyenjoybeingchallengedatalevelthatsuitstheirabilities.TheWheelof

Sukrframeworkanswersthisbyconsideringtheuser’sabilityandemployingtriggers.

Itisworthmentioningthatusingthemixed-methoddesignprovidedaclearimageoftheissue.It

createdabalancebetweentheweaknessesofqualitative(interviews)andquantitative

(questionnaire)methods(assuggestedbyJick(1979)),whichallowsforawell-rounded

representation.Moreover,thedatawerecollectedfrombothexpertandpatients,using

interviewsandquestionnaires.Theresultsfromtheinterviewsandthequestionnairesdo

complementeachother.Infact,relyingontheexpertinterviewsalonewouldhaveresultedina

lossofalltheimportantinformationprovidedbythepatientsandviceversa.

However,itisimportanttomentionthat,inSaudiArabia,thereisastigmasurroundingdiabetes

(Alzaid,2012).Themedicalexpertssupportedthisandasoneoftheparticipantssaidinthe

optionalcommentboxofthequestionnaire:

“Iwishthereismoreawarenessaboutdiabetesinmysociety,andthatpeople

wouldunderstandthatitisnotcontagiousandthatdiabeticswhotakecareof

themselvescancopeandliveanormallife.”

Thisstigmacouldhavebeenafactorindiscouragingindividualswithdiabetesfromparticipating

insuchstudies.Infact,itwaschallengingandtimeconsumingtogetpeopletoopenandtalk

abouttheirillness.Anonlinequestionnairewasthebestchoicetogettheopinionsofindividuals

withdiabetesinSaudiArabia.Forthisstudy,wemanagedtoget42participants,butitwasvery

difficult.Accordingtothetoolusedforthequestionnaire(SurveyMonkey)95peopleenteredthe

linkandansweredpartofthemultiplechoicequestionsbutonly42ofthemcontinuedtoanswer

thefullquestionnaire.

Additionally,giventheculturaldifferencescommunicatingwiththemedicalexpertsrequiredthe

researchertopersonallyapproachthedoctors,sinceitisnotcommontouse

emails/phones/videocallsforsuchpurposesinSaudiArabia.Therefore,ittooktimetogetthe

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expertsneededforthisstudy.However,thiseffortwasworthwhilegiventhattheexpert

interviewsstrengthenedthestudyasmentionedearlier.

Theresultsofthequestionnaireandinterviewscombinedsupportsallthethemesofthe

framework.Therewasnothingintheanalysisthatsuggestshierarchyorimportanceofonetheme

overtheother.Thus,theequalimportanceassumptionisstillvalid.Thisassumptioncanonlybe

testedinalongitudinalstudywhereanapplicationthatusestheframeworkcollectsdatafrom

individualwithdiabetesorotherchronicillnesses.

InafutureworktheimportanceofthethemesoftheWheelofSukrandtheirhierarchywillbe

studiedinthelongitudinalstudywherethethemesareimplementedinanappthatisusedbythe

intendedusersforasufficientperiodoftime.Inthisstudy,thethemesoftheWheelofSukrcan

bemeasuredseparatelytofindtheirleveleffectivenessintheself-managementofchronic

illnesses.Theimportanceofthethemesmightdifferbasedonthedemographic(e.g.ageofthe

targetusers).Thus,multiplestudiesshouldbeconducted.

Furthermore,whileallmeasuresweretakentoensureanunbiasedquestionnaire,biascannotbe

completelyremovedduetomisunderstandingofthequestions(sincethequestionnairesareself-

administered)orissueswithsomeofthequestions.Thus,inafuturestudy,tominimizethebias

onecouldeitherusestandardquestionsthatarevalidatedforacertainpurpose(e.g.engagement

instruments,orself-determinationtheoryinstrument).However,bothinstrumentrequiresthe

userstoengagewithagamifiedapplicationfirstandthentheresearchercanmeasuretheir

engagementandmotivation.

4.8 Summary

InthischaptertheWheelofSukr,whichisaframeworkthatgamifyself-managementofchronic

illnesses,wasintroduced.Theframeworkconsistsof28elementsthatweresynthesisedfromthe

literatureongamification,behaviouraltheories,andself-managementofchronicillnesses.It

emphasizesthelinkbetweentheseareasandgamificationintotheself-managementprocessof

chronicillnesses.Theelementsareencapsulatedineightthemes:

1. Self-management:logbook,visualizationofdata,andtrendalerts

2. Socializing:community,socialmedia,peer-support,andsharing.

3. Self-representation:avatars,autonomy,ability,andpurpose.

4. Fun:badges,points,challenges,andcompetition.

5. Esteem:leaderboards,levels,progressbars,andreputation.

6. Motivation:intrinsicandextrinsic

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7. Sustainability:trigger,flow,storyline/theme,andnudge

8. Growth:feedback,achievinggoals,andtinyhabits.

Theframeworkwasvalidatedusingamixed-methodapproach.Thequalitativeandquantitative

methodschosenwereexpertinterviewsandquestionnaires.Theexpertinterviewsconsistedofa

semi-structuredindividualinterviewswithexpertsfromdifferentbackgroundthatreflectsthe

threeareasofresearch.Therewereexpertsfrommedicaldoctors,psychologistandpsychiatrists,

andgamificationresearchers.Theinterviewswereaudio-recorded,transcribed,andanalysed

usingthematicanalysis.Thefindingsofthisanalysisshowaconsensusamongtheexpertsonthe

importanceofthethemesoftheframework.

Additionally,thequestionnairewasdistributedtoindividualswithdiabetesbasedinSaudiArabia.

Itconsistedoftwoparts,ademographicalandgeneralquestionpart,andaLikretscalepartto

measuretheparticipants’attitudetowardstheconceptsofframework.Thedatacollectedwas

analysedusinga1samplet-test(2tail)usingSPSS.Theresultsofthestatisticalanalysisvalidated

thethemesoftheframework.

Overall,thefindingsandresultsofbothstudiessuggestageneralacceptanceofthenotionof

gamifyingself-managementofdiabetes.Theyalsoshowthatitcouldbeimportantinimproving

theexperienceofpatients.TheWheelofSukrframeworksetsthestageforfurtherstudiessuchas

creatingdeveloperguidelinesforthegamificationofself-managementofchronicillnesses,which

isthesubjectofthenextchapter.

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Chapter5: TheSetofGuidelinesanditsValidation

Inthepreviouschapter,TheWheelofSukrframeworkwaspresentedforthegamificationofthe

self-managementofchronicillnesses.TheWheelofSukrwasvalidatedusingamixed-method

approach.Thisentailedexpertinterviewswithmedicaldoctors,psychologists,andgamification

experts.Theparticipantswereinterviewedinaface-to-facemanner.Thestudyalsoinvolveda

quantitativestudy,whereindividualslivingwithdiabetestookpartinansweringanonlineself-

administeredquestionnaire.Thiswasundertakeninordertomeasuretheirattitudestowardthe

conceptscoveredbytheframework.Theresultssuggestedthatparticipantsarekeentoseeself-

managementappscontainingtheconceptsofTheWheelofSukr.Additionally,thefindingsofthe

interviewssuggestthatexpertsseetheneedforgamificationasrepresentedintheframeworkin

theareaoftheself-managementofdiabetesandotherchronicillnesses.

InthischapterwepresentasetofguidelinesbasedonTheWheelofSukrframework.Thesetof

guidelinesismeanttoenabledeveloperstoincorporategamificationinthecreationofself-

managementappsforchronicillnesses.Theguidelinesareassessedbyexpertinterviewsand

discussedwithdevelopersinfocusgroups.Thepurposeoftheexpertinterviewsistoensurethat

theguidelinesrepresenttheframeworkaccuratelyandcomprehensively.Thepurposeofthe

focusgroupdiscussionswithdevelopersistwo-fold:Thefirstaimistocollecttheirviewsonthe

clarity,usefulness,andeaseofimplementationofTheWheelofSukrguidelines.Thesecondisto

testiftheycouldthinkofpracticalwaystogamifyappsbasedontheguidelines.

5.1 TheTransitionfromtheFrameworktotheGuidelines

TheWheelofSukrisatheoreticalframeworkandsoisconsideredahigh-levelconstruct.Itwas

constructedwiththeuserinmind(i.e.individualswithchronicillnessesespeciallydiabetes).After

fillingthegapintheliteraturebyproposingandvalidatingtheframework,theaimofthisphaseis

toadvancethisareaofresearchbyprovidingasetofguidelinesthatisbuiltwiththedevelopers

inmind.Thevalidationoftheframeworkwasanimportantstepforcreatingtheguidelines.

Otherwise,thesetofguidelinesitselfwouldnotnecessarilyrepresentagamificationapproach

thatissuitablefortheself-managementofchronicillnesses.

Toestablishthetransitionfromthetheoreticalsidetothepracticalside,theframeworkandits

contentshouldbetranslatedintoasetofguidelinesthatcanbeappliedpracticallybydevelopers.

Thiscanbeaccomplishedbydeconstructingtheframework,andpresentingthecontentfroman

anglethatissuitablefordevelopers.Consequently,thereisacrucialdifferencebetweenthe

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frameworkandtheguidelinesinthattheframeworkwasbuiltwiththeenduseroftheappin

mind,whichareindividualswithdiabetes,whiletheguidelinesarebuiltfordeveloperswhoare

responsibleforcreatingsuchanapp.Suchguidelinesshouldcontaindefinitions,instructions,or

suggestionsthattargetdeveloperswhocanthengamifytheself-managementofchronicillnesses

appsorsystems.

Thecurrentliteratureongamificationisnotdirectlyappropriateforthepurposeofdeveloping

gamifiedself-managementofchronicillnessesapps.Inparticular,gamifyingtheself-management

ofchronicillnessesisdifferentfromgamificationtoincreaseproductivityofemployeesasweare

dealingwithpatientsanddailyself-management.Furthermore,softwareengineersand

developersarenotexpectedtoknowtheliteratureonself-managingdiabetes,gamificationin

healthcare,andbehaviourchangemethods.AsetofguidelinesbasedontheWheelofSukr,which

isaframeworkforthegamificationofchronicillnessesself-managementandwasvalidatedby

expertsandpatients,couldbehelpfultoassistdevelopers.Guidelinesinfluencethedecisions

madeintheplanninganddesignphaseofdevelopingsoftwareandapplications,anditcanbe

usedasachecklistintheevaluationandtestingphase(Dixetal,2004).

Itisworthwhilementioningthatthereisawiderangeofguidelinesaimedataidingdevelopers

anddesignersinthefieldsofhuman-computerinteraction,softwareengineering,andweb

technology.Awell-knownexampleisNielson’sdiscountedusabilityengineeringguidelines,which

arecalled“heuristicsofusabilitydesign”(Nielsen,1994).Nielson’sguidelinesarenotveryspecific

butbroadrulesofthumbthatareusedbywebdeveloperstoguidethemthroughtheprocessof

creatingawebsiteinterfacethatiseasytousebyallusers,orasanevaluationtest(i.e.heuristic

inspection)toensuretheusabilityoftheinterfaceofthewebsiteinthe“testingandevaluation”

phase.

Thereexistguidelinesforgamificationineducationspecificallyintheuseofsocialgamificationin

k-6learning(Simõesetal.,2013).However,therearenoexistingguidelinesforthedesignof

gamificationofself-managingchronicillnessesapplications.Eventhoughthereisawidespread

adoptionofgamificationinhealthcareandsomeattemptsingamifyingself-managementof

diabetes(SeeSec.2.3.2),thereisalackofguidelinesforthedevelopmentofgamificationinthe

self-managementofchronicillnesses(Listeretal.,2014;Seaborn,Fels,2015).Thereisaneedfor

guidelinesinthisspecificfield(i.e.gamificationofself-managementofchronicillnesses).

ThesetofguidelinespresentedinthischapterisanewcontributiontothefieldofHCI,software

engineering,webtechnologyanddevelopment.ItisbasedonthevalidatedtheWheelofSukr

frameworkandliteraturereview.Inparticular,thethemesandtheelementsofTheWheelofSukr

arethebasisoftheguidelines.Itismeanttoofferguidanceintheprocessofdevelopinggamified

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self-managementapplicationsforindividualswithchronicillnesses.Thus,bridgingthegapinthe

areasofsoftwareengineeringandHCIregardingtheimplementationofgamificationfortheself-

managementofchronicillnesses.

Integratinggamificationintoanyapplicationorsystemcouldhavedifferentgoalsandobjectives

thatvarydependingonthecontext.However,itisessentialtohaveaclearguidefordevelopersin

ordertoachieveasuccessfulintegrationofgamification.Asmentionedintheliteraturereview

chapter(seeSec.2.1.5),thereisalackofguidelinesfordevelopersinthisfield,andresearchhas

shownthatcurrentgamifiedappsdonotfollowspecificguidelines.

“ThesetofguidelinesisbasedontheWheelofSukrframework,thus,itincludesallthethemes

andtheirelements.AsshowninCh.4,theelementsoftheframeworkaresynthesizedfromthe

literature(seeCh.2),andallthethemesthatencapsulatetheelementsreceivedsupportfromthe

medicalexperts,gameandgamificationexperts,andtheindividualswithdiabeteswho

participatedinthestudy.

AsshowninSec.4.5.2andSec4.6.2thefunandtheesteemthemesreceivedalotofsupport

fromboththeexpertsintheinterviewsandbypatientswhoansweredthequestionnaire.The

elementsoftheboththemesweresynthesisedfromthegamificationliterature,andtheyare

consideredfundamentalsofgamification.Thegamificationexpertsstatedthattheelementsof

thefunthemeandtheesteemthemeconstitutetheessentialprinciplesofgamification.Also,the

medicalexpertswelcomedtheideaofrewardingandcreatingcompetitionstomotivateand

encourageuserstoself-managediabetesdaily.Theresultsofthequestionnairereflectthe

supportforboththemesbythepatients.

Thesocializingthemereceivedalotofsupportfromalltheexpertsandthepatients.The

endocrinologistsandpsychiatristsdiscussedtheimportanceofbeinginacommunitywithother

diabeticandpeer-supporttopatientsofdiabetes.Also,thegameandgamificationexperttalked

abouttheuseofacommunityingamification,andthatitintegratesalltheotherelementsand

addstothevalueofgamification(e.g.rewards,andcompetitions).Thecommunityaspectwas

alsosupportedbyliteratureinbothself-managingdiabetesandingamification.

AstheWheelofSukrisaframeworkforgamificationfortheself-managementofchronicillnesses

the“self-management”themeisessential.Itreceivedsupportfrombothexpertsandpatients.

Medicalexperts,especiallyendocrinologists,supportedhavinganelectroniclogbookandthe

visualisationofdataasitmakesthepatientself-manageproperlyandthentheycanprovidetheir

doctorswithvisualrepresentationoftheirtestsresults.Furthermore,theliteraturereview

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showedthatthereisevidenceonthepositiveeffectsoftheuseelectronicappsinhealthcare.

Theseincludereducingreadmissionstohospitalsandtheprogressionsofdiseases(seeSec.2.3.1).

Thesustainabilityandthegrowththemesreceivedsupportinboththeexpertinterviewsandthe

patientsquestionnaire.Thegamificationexpertdiscussedtheimportanceofboththemesin

sustainingtheusers’engagementwiththegamifiedapp.Theexpertsdiscussedhowoneofthe

growththemeisdirectedattheuserintermsofprovidingthemwithfeedback,setgoalsand

achievethem,andbreakdownstepsoftheself-managementactivitiestocreatepositivehabits.

Ontheotherhand,thesustainabilitythemeismorerelatedtothesystemintermsofcreatinga

storylineoratheme(narrative)thatlinkstheotherelementsoftheframeworkandengagethe

user.Expertsalsosupportedtheimportanceofnudgingandusingtriggersinpersuadingusersto

undertaketasksintheapp.

Also,boththefindingsoftheinterviewsandtheresultsofthequestionnairesupportsthe

motivationtheme.Themedicalexpertsdiscussedtheimportanceofmotivatingpatientstoself-

managetheirillnessandthatsomepatientsmightlackmotivation.Thiswasalsoreflectedinthe

patientsquestionnaireweretheresultsweredividedbetweenthosewhoagreedtothelackof

motivationandthosewhowereneutral.Furthermore,thegamificationexpertsalsodiscussedthe

valueofdistinguishingbetweenintrinsicandextrinsicmotivationwhenusinggamification.This

wasalsosupportedbyliteratureasdiscussedinSec.2.2.1

Itisworthmentioningthatsomeempiricalstudies(ingamificationforeducationspecifically)

showthattheoutcomesofgamificationareprimarilypositive,buttherearesomedrawbacksin

termsoftheuseofleaderboards(Hamariet.al,2014).Thiscouldbebecausenotallusersare

competitive;someusersfindcompetitionsmotivatingandothersaredemotivatedbyit(Werbach

andHunter2012).However,theWheelofSukrguidelinestakeaholisticapproachtogamification

thatincludesalltheelementsthatmotivateusers.Anyelementthatmighthaveademotivating

effectsonsomeuserscanbemadeoptionaltoaccesstotheusers,whichisthecaseinmostapps.

Inparticular,thedevelopercanmaketheaccesstoleaderboardsoptional,thosewhodonotwant

tosocialiseorcompetewithotherscansimplyignorethisfeatureintheapp.Forexample,those

whousesomefitnesstrackerappscanchoosetowithholdfromsharingtheirdatawithothers

andnotfollowotheruserseventhoughtheappincorporatessocialandcompetitiveaspects(i.e.

leaderboards).Thiscouldbetherightapproachtocatertothosewhofindmotivatingor

demotivatingbecausetheyhavethechoicetoaccessitornot.”

Thesetofguidelinesproposedinthischapteraimstoaiddevelopersincreatingagamifiedself-

managementsystemforchronicillnesses.Itwillprovide“what”shouldbeincludedinagamified

self-managementapp.Thethemesthatareincludedintheguidelinesarediscussedinthe

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followingsection.Inparticular,eachthemeisexplainedintermsofitsrelevancetodevelopers

andtheprocessofplanning.

1.FunTheme:

Thefunthemerepresentswhatisconsideredasthebasicgamificationelementsthatenablethe

creationofagame-likeexperience.Inanappthattargetstheself-managementofchronic

illnesses,arewardsystemcanbeimplementedthroughtheuseofthegameelements,namely

badgesandpoints,andthecreationoffriendlycompetitionsandchallenges.

Thepointscanbeassociatedwithsmallerandmorerepetitivetasksthatarerelevanttotheself-

managementprocess.Forexample,userscanbeawardedwithpointsforenteringtestresults,

completingtheminimumrequiredtestsperday,completingaweekofenteringtestresults,

completingachallenge,andwhencommunicatingwithotherusers.

Thebadgescanbeawardedtousersatmultiplestagesbasedontheobjectivesoftheapp.For

example,itcanbegiventousersatregistration,uponcollectingpoints,andwhencompleting

milestonetasksintheself-managementofanillness,suchaskeepingadailylogbookforamonth.

Inaddition,thecreationoffriendlycompetitionscanbedesigneddirectlybythedeveloper,orit

couldarisedynamicallybyacombinationofotherelements.Forexample,thedevelopercan

createweeklycompetitions.Ontheotherhand,theuserscancompeteamongstthemselvesto

collectmorebadgesorscorehigherontheleaderboard.

Challengescanbedesignedbythedevelopertobecompetedwithatimelimit.Forexample,

completingaweekofenteringtestresults.Moreover,bothchallengesandcompetitionsshould

notberelatedtotheresultsofthetestsandcommonsenseshouldbeappliedinsimilar

situations.Thesensitivityoftheissueshouldbetakenintoaccountwhiledesigningcompetitions

andchallenges.

2.EsteemTheme

Theesteemthemeembodiestheelementsthatcouldcreatefeelingsofadmirationandrespect

fortheuser.Inthecommunityofanappthattargetstheself-managementofchronicillnesses,

esteemcouldbeaccomplishedbyutilisingleaderboards,levels,progressbars,andreputation.

Leaderboardscanbeassociatedwiththepointsorbadgescollected.Theycanbelinkedtothe

pointscollectedforkeepingadailylogbookoftestresultsorbythenumberofbadgescollected.

Progressbarscanbedesignedtoshowtheuserhowwelltheyareprogressingthroughtheirdaily

tasksofself-management.

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Moreover,thedevelopercancreateLevelsfortheusertogothroughbyaccomplishingspecific

goalsorcollectingbadges.Thelevelscanbelinkedtothestorylineandthemeoftheapp,oritcan

belinkedtothetimetheuserspendsusingtheapp.

Thereputationelementiscreateddynamicallythroughtheuseofleaderboardsinthecommunity.

Alltheofthepreviouselementscancontributetotheadmirationandrespectwhentheuser

engagewiththeappandfindthemselvesadvancingintheirinteractionwiththeappandthe

community.

3.Growththeme

Thegrowththemerepresentstheelementsthatcouldhelpusersintermsoftheirself-

managementskills,whichcouldbeaccomplishedthroughtheuseofthefollowingelements:

feedback,achievinggoals,andbabysteps(tinyhabits).

Feedbackcouldbegiventotheuserbasedontheirtestresultentriesandtheoverallperformance

intheapplication.

Goalscouldbesetbytheuserorthedeveloper.Theycouldbelinkedtoself-managementtasks.

Forexample,userscansetgoalsforthemselvestobepersistentintestingandloggingtheresults,

ortheycanbepre-existingintheappandrelatedtotheteststhemselvesonlyiftheyaresetby

healthprofessionals.

Thedailytasksofself-managementcanbebrokendownintosmallersteps(babysteps/tiny

habits)tomakeiteasierfortheusertoadoptnewhabits.

4.Motivationtheme

Themotivationthemerepresentsthetwotypesofmotivation:intrinsicandextrinsicmotivation.

Inanappfortheself-managementofchronicillnesses,usersmaybeintrinsicallymotivatedto

self-managetheirillnesstobecomehealthier.

Intrinsicmotivationcouldbeenhancedthroughtheuseofotherelementssuchasachievinggoals,

andthevisualrepresentationofdatawhichcouldcreatefeelingsofmasteryandautonomy.

Extrinsicmotivationcouldcomeintheformofrewards(i.e.points,badges),winingcompetitions,

oradvancingintheleaderboardtogainstatus.

5.Sustainabilitytheme

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Thesustainabilitythemeembodiestheelementsthatcouldleadtosustainableengagementfrom

usersinaself-managementapp.Thisiscoveredinfourelements:trigger,flow,storyline/theme,

andnudge.

Thetriggerelementisimplementedbythedeveloperasamessageorasound.Triggerscouldbe

usedtoremindtheusertochecktheapp,entertestresults,orcommunicate.

Theflowelementisrealisedbydesigningtheactivitiesintheappaccordingtotheuser’sskilllevel

inwhichthedifficultyoftheactivitiesgraduallyincreasesastheuser’sskillsincrease.

Forthestoryline/themeelements,thedevelopercancreateameaningfuljourneythatmakesthe

userpartofitandincreasestheirengagement.Otherelementssuchaslevelsandcompetitions

couldalsobepartofonestorylineortheme.

Thenudgeelementcanbeimplementedbythedeveloperthroughcreatingdefaultchoices.For

example,whentheapptriggerstheusertoentertestresults,thedevelopercancreateanoption

foruserswhowanttoskiptheentryandremindthemafteracertainamountoftimewitha

reminderboxthatneedstobetickedasadefaultoption.

6.Self-representation

Theself-representationthemeencompassestheelementsthatcouldcreatealinkbetweenthe

userandthesystemintermsofreflectingtheuser’sidentity.Ithasfourelements:avatars,

autonomy,ability,andpurpose.

Developerscanallowuserstocreateorcustomisetheiravatarstoexpressthemselvesandcreate

aconnectionwiththeapp.

Whendesigningthetasks,challenges,competitions,andotherelements,theuserdevelopermust

takeintoconsiderationtheabilityoftheusers.

Theautonomyoftheusershouldbeincreasedbygivingthemchoiceswheneveritispossible.

Autonomyisalsocloselyrelatedtotheflowelementofthesustainabilitytheme.

Thedevelopercanenhancethesenseofpurposeoftheuserbyacombinationofotherelements.

Theseelementscouldrangefromtheself-managementtasksandthevisualrepresentationof

datatobeingpartofacommunityandofferingpeer-support.Thedevelopercangiveusersthe

chancetohelpotherssuchasbygivingthemtheabilitytogivebadgestootherhelpfulusersin

thecommunity.

7.Socialisingtheme

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Thesocialisingthemerepresentsthesocialaspectoftheself-managementofchronicillnesses.It

iscreatedthroughtheuseofcommunity,socialmedia,peer-support,andsharing.

Thedevelopercancreateacommunity,i.e.anetworkwithintheself-managementappwhere

userscancommunicate.Thiscouldalsobelinkedtootherelementssuchasthefunandesteem

themeelements.

Developerscanalsoprovideuserswiththechoiceoflinkingtheiraccountswithintheappwith

othersocialmedianetworkssuchasFacebookorTwitter.

Peer-supportisprovidedthroughthecommunityandthesocialmediafeatures.

Furthermore,developerscangiveusersthechoicetosharetheirtestresults,progressand

achievementswithotherswithintheappcommunityorwithlinkedsocialmedianetworks.

8.Self-management

Self-managementisconsideredtheessentialpartforthisapp.Thisiscoveredbythreeelements:

alogbook,thevisualizationofdata,andtrendalerts.

Thelogbookcanallowuserstokeeptrackoftheirtestresults,datesandtimes,foodintake,

exercise,feelingsandotherrelevantinformation.

Thedatasavedinthelogbookcanbeturnedintovisualdatasothattheusercanbenefitfromthe

accumulatedinformation.Forexample,withthevisualizationofdataelementstheusercan

followtheirprogressoveraparticularperiodoftime(e.g.thepastweekormonth),enabling

themtospotpatternseasier.

Trendalertsarealsobasedonthedataenteredbytheuser.

TheGuidelinesStructure

TheguidelinesarebuiltbasedonTheWheelofSukr.Similartotheframework,theguidelines

contain8themes,eachofwhichisdividedinto5sectionsasshowninTable5-1.

Table5-1SectionsoftheGuidelines

Theme Ageneralconstructcontainingelementsthatsharethesamegoal.

Definition Thegeneralideaofthethemeisdefined.

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Goal Thepurposeofthethemeanditselementsarestated.

Description Thethemeanditselementsareelaborated.

Application Thethemeistranslatedintopointerstohelpinimplementation.

TheWheelofSukrguidelinesaredesignedsuchthattheycanbetailoredtothegoalsand

objectivesofeachapporsystemanditsaudience.Forexample,thetypeofbadgesandpoints

couldbedifferentiftheappistargetingchildrenwithdiabetesasopposedtoadults.The

guidelinesshouldreflectTheWheelofSukraccurately,andbecomprehensivesuchthat

developerscanusethesetofguidelinesdirectlywithoutneedingtogobacktotheframework.In

addition,theguidelinesshouldbeclearandusefultodevelopers,andeasytoimplementfrom

theirpointofview.

Theguidelinesarepresentedinthenextsectionintheformoftables;eachthemeofTheWheel

ofSukrhasitsowntable.Thetablesaredividedintothemesandtheirelements,adefinitionof

thetheme,thegoalofthetheme,thedescriptionoftheelementsinthetheme,andthe

applicationofthetheme.

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5.2 TheWheelofSukrGuidelines

Inthissection,thefinalversionofthesetofguidelinesisrepresentedineighttablesbasedonthe

structureoftheframework.

GuidelinesforGamifyingSelf-managementofChronicillnesses

FunTheme(Badges,points,challengesandcompetition)Definition The fun theme has the basic building blocks of any gamification

system. It represents the rewarding features of gamification andenablesthecreationofagamelikeexperience.

Goal Createarewardingandengagingexperience.Description • Thebadgeselement indicates the specialdesigns that canbe

awardedtousersasasignofmembershipandachievement.Itcanbeawardedtousersoncetheystartusingtheapplication,whenaccumulatinganumberofpoints,andwhencompletingalevel.

• The points element indicates the points that are awarded tousers when entering test results, completing the minimumrequired tests per day, completing a week of entering testresults,completingachallenge,andwhencommunicatingwithotherusers.

• Thechallengeselementindicatesthemotivatorscreatedinthegamified system to get users to engage in difficult butobtainable tasks. These could be completing a week ofenteringtestresults,ormaintainingacertainlevelofglucose.

• The competition element indicates the competitiveenvironment that can be created using the elements in thisthemeandotherthemes(suchas levelsandleaderboards)toincrease user engagement. The competitive environmentshouldbeexclusivetotheactivitiescompleted(i.e.thenumberof times the user logged in, the user’s involvement in thecommunity, completing tasks… etc.) and not regarding theirtest results. Users can compete with each other in thecommunityandwiththemselves.

Application Design a system of rewards (points and badges) based on thecommunity you are targeting and on the unique goals of theapp/system.Createchallengesforuserstoincreasetheirengagementandhelpthemmeettheirgoals.Giveuserstheoptiontovieweachother’sachievements.Design thecompetitionswith theuser inmind(i.e.donotcreateinsensitive competitions regarding their test results). Make theexperiencepositiveandrewarding.Rememberthatcollectingbadgesandpointsisamanifestationofthe “collection” core dynamics in games and you could usedifferentmanifestationofcollection.� This theme is closely related to the Esteem and Motivation

themes.

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EsteemTheme(leaderboards,levels,progressbars,andreputation)Definition Theesteemthemeencompassestheessentialelementsneededto

createfeelingsofrespectandadmirationfortheuser.Itcommunicatesthestateofthesystemtousers.

Goal Enableuserstorespectandadmiretheirownachievementsandthoseofothers.

Description • The leaderboard element indicates the leaderboards that areused in video games. Similar to video games, in gamificationleaderboardsaresocialfeaturesusedtoincreaseengagement,motivation,andthelevelofcompetitionbetweenplayers.Thisis done by ranking them in a number of ways such asaccording to thenumberofpointsorbadgescollectedor thelevelsachieved,etc.Therearedifferenttypesofleaderboards,such as global leaderboards,which rank the topusers of theapplication, and friends or social leaderboards that rank theuser’s friends or those in their social network (Twitter,Facebook...etc.).

• The progress bar element is a graphical element in the userinterfacethatshowstheprogressionoftheuserandhowclosehe/sheistocompletingasetoftasks.Itcouldbeexpressedasapercentage,invisualformoratextualrepresentation.

• The levels element indicates the part of the application thatusersneedtocompletetomeetspecificgoalstoadvancetothenext level. The difficulty of every level increases as the usercompletesnewlevels.

• The reputation element indicates the user’s status, rank andexpertise in the community. It is the way in which usersshowcasetheirpointsandbadges.Reputationmechanicsmustbedesignedandupdatedbasedonthecommunity.

Application Designleaderboardsandchoosethetypeortypesofleaderboardsthatfitthecommunityandtheapp/systemgoal.Createaprogressbar thatmeasures theuser’sactivitybasedonthegoaloftheapp.Forexample,measuretheuser’sinvolvementin the community or the user’s progress in logging their testresults.Design levels based on the goal of the app, considering thestorylineandthemeelements(fromthesustainabilitytheme),andtherewardandcompetitionelements(fromthefuntheme).Design feedback, leaderboards, progress bar, levels and thecommunity(fromthesocializingtheme)coherentlytoutilizethereputationmechanicswheretheusercanshowcasetheirstatusinthecommunity.Considerthesensitivityoftheissuewithregardstosocialgamingandthelevelofconfidentialityinvolved.

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Growththeme(feedback,achievinggoals,andbabysteps(tinyhabits))Definition Thegrowththemerepresentstheelementsthataidtheusersin

growinganddevelopingintheself-managementoftheirchronicillness.

Goal Empowerpatientstotakegoodcareoftheirhealthbylearningabouttheirillnessandlearningtomanageit.

Description • The feedback element indicates the comments users receiveregarding their test results entries and their overallperformance in the application (their self-managementhabits).

• Theachievinggoalselementindicatesoutliningcleargoalsandrulesinthesystem.Goalscouldalsobesetbytheuserorwiththe help of caregivers. These could include self-monitoringblood glucose, such as the frequency of blood testing, andwhetherthepatientkeepsalogofthetestsornot.

• Thebaby steps/tinyhabits element indicates thebreakdownof activities into a sequenceof smaller tasks that are easy toincorporate into the users’ daily routine. This is believed toresult in the adoption of the new “tiny habits” to reach adesired behaviour. This helps in changing behaviour in self-management.

Application Designafeedbacksystembasedonthegoaloftheapp/system.Linkthefeedbacksystemtothepointsandbadges.Setgoalsforuserstoencouragethemtostartwiththeself-managementtasks.Giveuserstheoptiontosettheirowngoals.Rememberthatbreakinggoalsandchallengesintosmallerstepswouldmakeiteasierfortheuserstoadopt.Donotmaketasksandgainingpointsandbadgestoodifficultfortheusertoavoiddecreasingtheirengagementandinterestintheapp/system.Increasethedifficultyastheirexperienceincreases.� Thisthemeiscloselyrelatedtotheself-managementtheme.

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Motivationtheme(intrinsicmotivations,extrinsicmotivations)Definition Themotivation theme includesmotivators thatare innate to the

user and extrinsic motivators. Both types of motivators areimportantinthedesignofgamifiedapps/systems.

Goal Utilizeextrinsicmotivatorstoincreaseintrinsicmotivation.Description • Theintrinsicmotivationelementindicatestheinnatedesireto

performanactivityfortheloveandjoythatitbrings.Intrinsicmotivators could include health, social satisfaction, status,mastery,purpose,acceptance,andcuriosity.

• Theextrinsicmotivationelementindicatestheperformanceofanactivitysolelyfortheexternalrewards,whichcouldincludepoints,rewards,andgainingstatus.Itincludesfourtypes:

o External regulation: results from outward rewards orpunishments.

o Introjection: results from self-esteem issues such asdoing something to avoid guilt or anxiety, or to boostone’sego.

o Identification:occurswhenapersonself-identifieswiththe importance of a behaviour and has accepted it astheirown.

o Integration: external motivation that has beeninternally integrated by the user. This type ofmotivation shares qualities with intrinsic motivation,suchasautonomyandbeingunconflicted.

Application Knowyourtargetaudienceandwhatmotivatesthem.Rememberthattheself-managementtasksthatpatientsshoulddomaynotfeelinherentlyinterestingorenjoyabletothem.Thiscouldbeduetothelackofperceivedautonomyandcompetence,whichareessentialforintrinsicmotivation.Utilizethetypesofextrinsicmotivationsthatcouldpromotemoreactive and volitional (as opposed to passive and controlling)formsofextrinsicmotivation.

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Sustainabilitytheme(trigger,flow,storylineandtheme,andnudge)Definition Thesustainabilitythemeincludeselementsthatensurelongevity

andcontinuoususerengagementandinterest.Goal Ensurethelongevityofthegamifiedeffectandencourage

consistentandbetterself-managementhabits.Description • Thetriggerelementindicatesthevisualoraudiomessagesor

cues that could triggerbehaviour. In the context of the self-managementofdiabetes,atriggercouldbeamessagetotheusertoremindhim/hertoentertestresults,orcommunicatewithothers...etc.

• The flow element represents themental state of absorptionandengagementinanactivityoragame.Intheflowstate,theuser is intrinsically motivated and completely immersed inwhat they are doing. The gamified activities in the self-management application should be designed according tousers’ skill level, thus, gradually increasing the difficulty astheusers’skillsincrease.

• Thestorylineandthemeelementsindicatetheimportanceofcreating a link between the user and the application. Thethemeisthebackgroundthattheusermightconnecttoatthebeginning, whereas the storyline is about controlling theprogress and the arc theuser takes through the experience.These elements also give more meaning to gamificationfeatures,creatingajourneythatmakestheuserpartofitandincreasestheirengagement.

• Thenudgeelementisbasedononeofthetheoriesknowntodrivebehaviour-nudgetheory.Anudgeistheuseofpositivereinforcement and indirect signals to lead to a non-forcedactionbycreatingthesimplestpathtocertainbehaviour.

Application Create a bondwith the user, through introducing a theme andconstructingastorylineintheapp/system,andcreateajourney.Design reminders for the user to log their daily test results byusingtriggerssuchassoundcuesormessages.Nudge the user into the desired behaviours you want them toundertake. For example, showing them the logbook once theysignuptotheapptoencouragethemtofillitinfirst.

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Self-representation(avatars,autonomy,ability,andpurpose)Definition Theself-representationthemesignifiestheimportanceofcreating

alinkbetweentheuserandtheapp.Goal Enhancethegamificationexperienceandefficiencyofself-

management.Description • Theavatarelementmeansprovidingtheuserwiththemeans

to express themselves in terms of allowing them to uploadprofile images, offer predesigned images for them to choosefrom,orallowthemtopersonalisetheirprofiles.

• Theautonomyelementoccurswhentheusershavefullcontrolovertheirchoicesandactivities.

• Theabilityelementsuggests thatdevelopersshouldconsiderthevariedabilitiesofusersandthat theyshouldsimplify thetasksrequired.

• The purpose element indicates that the goal and purpose ofself-managementiscleartotheuser.

Application Givetheuseroptionstoexpressthemselvesinthesystemtohelpthemcreateabondwiththesystem.Rememberthattokeepandenhancetheuser’sintrinsicmotivation,theymustexperiencetheirbehaviourtobeautonomous.Designthechallenges,tasksandothergamificationfeaturesinanobtainableway.Clarifytheimportanceofthetasksandactivitiesintheapp/systemtousers.

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Socializingtheme(community,socialmedia,peer-support,andsharing)Definition Thesocializingthemecoversthesocialandemotionalaspectof

self-managingdiabetes.Goal Provideuserswithacommunitythatcreatesabaseforthe

gamificationfeaturesandoffersthememotionalandsocialsupportfordiabetics.

Description • The community element means creating a network that isheld together by the shared experience of having chronicillnessandthecommongoaloflivingahealthylife.

• Thesocialmediaelementmeansprovidingtheuserwiththechoice to link his/her self-management profile or activitieswith theirother socialmedia accounts suchasFacebookorTwitter.

• The peer-support element indicates the support that isprovided through the community (other users in the app),thesocialmedia(iftheappislinkedtosocialmediasuchasTwitter and Facebook), and the gamified features such asfeedbackandrewards.

• The sharing elements involve providing the user with theoptiontosharetheirtestresults,progressetc.,withothersinthecommunity.

Application Create a community where users can share their experiencesandlearncopingstrategiesfromeachother.Allowuserstolinktheirprofilestotheirsocialmediaprofilesinwhichtheycansharetheirachievementsandrewardswiththeirfamilyandfriendswhoarenotinthecommunity.Link the fun theme, esteem theme, and sustainability themeelements with the community and social media features toenhancethevalue ofrewards,challenges,andcompetition.

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Self-management(logbook,visualizationofdata,andtrendalerts)Definition Theself-managementthemecoverstheessentialelementsofa

diabetesself-managementapp/system.Goal Assistusersinself-managingtheirillnessinanefficientway.Description • Thelogbookisaspacethatallowstheusertokeeplogson

theirtestresults,date/time,foodintake,exercise,howtheyarefeeling,andotherrelevantinformation.

• Thevisualizationofdataelementindicatesturningthedataintheuser’slogbookintovisualrepresentations.Inthisway,theuser can benefit from the accumulated information. Forexample,ausercanseehowwelltheydidinthepastweekormonthusingatableoraspecificgraph.Moreover,thiswouldenablethemtospotpatternseasier.

• Thetrendalertelementindicatestheuseoftheloggeddatatoalerttheuserofanysuddenchangesorworryingresultssuchasextremelows/highsintheirbloodglucose,etc.

Application Createalogbookwhereuserscanenterallthedatatheyneedtosave from their daily medical test results. For example, bloodglucose level, insulin injection, psychological state, food intake,andactivities.Creategraphsandchartsfromthedatasavedbytheuser.Presentthesegraphsinweekly,monthly,andyearlyoptions.Alerttheuserofanytrendssuchasverylow/highbloodglucoseoriftheuserdidnotentertheirtestresultsduringtheday.Considertheprivacyoftheuser’sdata.

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5.3 ValidationoftheGuidelines:Multi-Methods

Thesetofguidelinesisvalidatedusingamulti-methodapproach.Theresultsoftwoqualitative

studiesaretriangulatedforthevalidationoftheguidelines(Figure5-1).Inparticular,interviews

withexpertsfromacademia(withexpertiseingamification,seriousgamesforhealthcare,user

experienceandgamedesign)assessedtheguidelines.Theexpertinterviewswereaimedat

confirmingthattheguidelines,asawhole,arecomprehensive,clear,andreflecttheframework.

Theotherpartofthemulti-methodapproachwasfocusgroups,wheredeveloperswere

interviewedingroupstovalidateanddiscusstheguidelines.Thevalidationhereistoconfirmthe

guidelinesproposed,findoutwhethertheproposedguidelinesarecomprehensive,andtoknow

whethertheproposedguidelinesarepractical.

Figure5-1ComponentsofTriangulationofGuidelinesValidation

Unlikethevalidationoftheframeworkmentionedintheprevioussection,thevalidationofthe

guidelinesconsistedoftwosequentialsteps.First,theexpertinterviewswereconductedandthe

findingswereanalysed.Itwasessentialtogetthefeedbackofexpertsfromacademiaonthe

contentoftheguidelines,andwhetherornottheyreflectedthevalidatedframework.Then,the

guidelinesareupdatedbasedonthefindingsandtherecommendationsfromtheexperts.After

that,thesecondstudytookplace,whereanumberofdevelopersareinterviewedinfocusgroups,

andthefindingswereanalysed.Thisstudywasconductedtoensuretheclarity,usefulness,and

easeofimplementationfordevelopers,whomaretheenduseroftheguidelines.Next,thefinal

versionoftheguidelineswascreated.

TheethicalapprovalforbothstudieswasobtainedfromtheEthicsCommitteeoftheUniversityof

Southamptonpriortoconductingtheinterviews(referencenumber:ERGO/FPSE/20757).

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5.4 Study1:ExpertInterviews

Toensuretheaccuracyandclearnessoftheguidelines,expertsfromacademiaassessedthe

guidelines(study1)andthenthesewerediscussedwithdevelopersinfocusgroups(study2).Itis

worthmentioningthatthegroupofexpertsandthegroupofdevelopersdidnotoverlapinour

study.Moreover,priortoconductingthestudy,pilotingwascompletedwiththreeresearchers

fromtheUniversityofSouthampton.

Inthissection,theinterviewsdesignandprocessbywhichtheywereconductedisdiscussed.

Also,thefindingsoftheinterviewsarepresented.

5.4.1 InterviewsDesignandProcess

Qualitativedatawascollectedthroughexpertinterviews.Theaimoftheinterviewswasto

conductaformativeevaluationoftheguidelinestoensurethattheyrepresenttheframework

accuratelyandcomprehensively.TheexpertswereselectedfromtheUniversityofSouthampton.

Theywereidentifiedandcontactedinpersonorthroughemailbythefirstauthor.Theyarefrom

oneormoreofthefollowingareas:gamedevelopment,userexperience,andgamification.

Asdiscussedearlier(seeSec.3.1.1.1),therearedifferenttypesofinterviews;inthisstudywe

choseasemi-structuredinterview.Ineachinterview,theresearcherstartedbyexplainingthe

backgroundofthestudyandtheframework.Next,theexpertwaspresentedwiththeguidelines,

andwasaskedtoreadonethemeatatime.Then,theresearcheraskedtheexpertanumberof

open-endedquestionstostartaconversation.

Semi-structuredinterviewswereconductedwithexpertsindevelopingappsandgames,experts

indesignanduserexperience,andgameexpertsinacademia.Theinterviewerstopped

conductinginterviewsafterreachingthepointofsaturation.Thispointiswhendatabecomes

redundantandnonewdataarefound(GuestandJohnson,2006;Bodenheimer,2002).Saturation

wasachievedafterinterviewing6experts.

Asmentionedinthepreviously(seeSec.3.1.1.1),thesaturationlevelaffectsthenumberof

participantsinexpertinterviews.Inthisstudy,saturationwasachievedafterinterviewingsix

experts.Thus,nomoreinterviewswereconducted.Moreover,itiscommontohavesmaller

samplesizesinstudieswithmorethanonemethod(Lee,WooandMackenzie,2002).

Thedurationofeachinterviewwas50minutesonaverage,andeachinterviewwasaudio

recordedafterobtainingapprovalfromtheparticipant.Afterthat,theinterviewswere

transcribedverbatimandwereanalysedusingathematicanalysisapproach.Thedatawerecoded

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withtagsthatrepresenttheeightthemesoftheguidelines.Similarsetsofdatawereidentified

andcategorized.

Thefindingsfromtheanalysiswereusedtoupdatetheguidelinesbeforeconductingthesecond

study(focusgroupinterviews).

5.4.2 InterviewsFindings

Inthissection,thefindingsoftheexpertinterviewsarepresented.Thefindingsoftheexpert

interviewsweredividedintoeightsubsectionsaccordingtothethemesofTheWheelofSukr.

TheexpertinterviewswereaimedatconfirmingthatTheWheelofSukrguidelinesasawholeare

comprehensiveandclear,andreflecttheframework(theWheelofSukr).

Theexpertsacknowledgedtheimportanceofintroducingsuchguidelines.Theyprovideda

numberofsuggestionsthatweretakenintoaccount.Overall,theexpertsthoughtthatthe

guidelinesprovidegoodguidancefordevelopersandhaveenoughinformationtohelpthemin

thisarea.Moreover,theysaidthatthewaytheguidelinesarearrangedflowsnicely.Theexpert

commentsandfeedbackaredividedbasedonthethemesoftheframework.

Fun

Thediscussionshowedthatthereisageneralconsensusamongsttheexpertsthatthispartofthe

guidelinesisunderstandable,easytouse,andcomprehensive.Theyalsoagreedthatthepoints

discussedintheguidelinesarefundamentalinmakingtheself-managementexperiencefunand

rewardingasoneoftheexpertssaid:

“Theinformationyouhaveunderthisthemeisappropriate,andinagamification

approachyouneedthesefourelements.Youneedsomethingtowinlikeabadgeor

somethingthatgivestheuserasenseofachievementandthatcanbecomparedand

sharedwithothers.Inthegamificationworldthisispartoftheexperience.Challenges

areimportantaswellbecauseitkeepsthemomentumandkeeppeopleinterestedand

engagedotherwisetheyreachacertainlevelandtheyloseinterest.”

Moreover,theexpertsagreedthattheguidelinesaregeneralenoughtobeusedincreating

differentapps.Asoneexpertstated:

“Itisveryclearanditisnotveryspecificthatitcanonlybeappliedtoasinglecasewhich

isgood.”

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Nevertheless,oneissuethatneededclarificationistheuseofcompetitioninthecontextof

chronicillnessself-management.Competitionshouldnotbeassociatedwiththeself-managing

tasksthemselvesortheresultsofthemedicaltestsbutratherwiththenumberoftimestheuser

interactswiththesystemorthelevelofengagementtheuserhaswiththecommunity,thereby

gamifyingtheexperienceofself-management.Consequently,aclarificationremarkwasaddedto

thecompetitionelementintheguidelines.

Someexpertssuggestedconsideringtheuseofothercoredynamicsorothermanifestationsof

thecollectioncoredynamic.Fromagamedesignpointofview,thebadgesandpointsare

manifestationsofthecoregamedesigncollection.Thismanifestationisthemostusedin

gamificationingeneral.However,thisdoesnotmeanthatdevelopersarelimitedtothisformof

coredesign.Inlightofthisfinding,theguidelinesfortheFunthemewereimproved.Othercore

designelementswerementionedinawaythatisstilltruetotheresearchandtheframeworkof

rewardingtheuser,notjustcreatingagame-likeexperience.Itisimportanttokeepinmindthe

goaloftheFunpartoftheguidelines,whichistomaketheexperienceofself-managingchronic

illnessesefficientwhilebeingenjoyableandpositive.

Esteem

Therewasstrongsupportforthispartoftheguidelinesandthewayinwhichitispresented.This

isevidentfromthecommentsofoneexpert:

“Thewayyoudescribedhowthey[theelements]needtobeimplementedintermsof

theleaderboardandtheprogressbarisaverycoherentwaytorepresenthowto

encourageesteembothinthecommunity(theexternal)andtheinternalintermsof

howthepersonseesthemselvesinthatcommunity.”

Onepointofclarificationisthatitisimportanttoconsiderwhattheusersmightnotwanttoshare

withothers.Forexample,inself-managingdiabetessomepeoplemightnotbecomfortable

sharingtheirbloodglucoselevels.Thisissuewasraisedbyoneoftheexpertsandtheguidelines

weremodifiedaccordingly.

Anotherexpertstressedtheimportanceofcreatingfeelingsofrespectandadmirationforthe

user:

“Ibelievethisisextremelyimportantbecauseofthewaythattheuserneedstoknow

theirprogressandkeeptrack.”

Theexpertalsomentionedthevalueofhavingreputationinthecommunity:

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“Itisalsoimportanttoenabletheusertoberecognizedbythecommunityasa‘super

user’orsomethinglikethat.”

Moreover,itwaspointedoutthatinthechronicillnessescommunitiesthecontentofthistheme

isparticularlyuseful.Thisisduetothefactthatitallowsthosewhodowellinself-managementto

beanexampletoothersandinspirethemwithoutpointingouttootherusersthatyouhavetobe

likehimorher.Astheexpertsaid:

“Thosewhokeeptrackoftheirself-managementactivitiesanddowell,theywillbecome

anexampleandanencouragementtoothersinthecommunity,anditwillhappen

naturally.”

Additionally,onusinganappforself-managementthathastheelementsoftheEsteemtheme,

theexpertsaid:

“Inthisenvironmentthemotivationcouldbeevenstrongerthanthatof[other

entertainmentgames]becauseitisrelatedtousers’health.”

Growth

Theimpressionaboutthispartoftheguidelineswasverypositive.Expertsacknowledgedthatthe

guidelinesareeasytounderstand,comprehensive,andreflecttheWheelofSukr.Thisis

exemplifiedinwhatoneoftheexpertsstated:

“Iagreewiththeelementsthatyougot...andthewayyouwanttolinkthesystemtothe

pointandbadgessothatthepersoncanseehimselforherselfgrowingintermsof

changingtheirbehaviourandstarthavingmorecontrol.”

Regardingtheelementsrelatedtoachievinggoalsandbabysteps(tinyhabits),oneexpertsaid:

“Weneedacombinationofdifficultandeasytasksfortheuser,andthelevelof

difficultyneedstoincreaseinordertoretainengagement.Thisisbecauseiftheuser

startsbecominganexpertinwhattheydoandtheymanagedtochangeatinyhabit

thensurelyyouwanttoincreasethedifficulty.”

Motivation

Theexpertsagreedonthecomprehensivenessandclarityofthecontentofthisguideline.One

experttalkedaboutlinkingintrinsicmotivationtotheapporsystemtohelpusersunderstandthat

thereasontheyarefeelingbetterisbecauseofwhattheyaredoingintheapp.Thiscouldbe

donethrough:

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“...promptingpeopleyoucanimaginehavingthingslike‘Ohthisweekyoumanagedto

dobetterthanyoudidlastweek.’”

Moreover,oneoftheexpertsdiscussedtheageaspectandsaid:

“Icanseethisworkingforbothchildrenandadults.Thebadgesworkforallagegroups.

Perhapsthecolourswouldchangeandthethemebuttheelementsworkwellforallthe

ages.”

Overall,themotivationguidelineswereclearandcomprehensive.Thisisexemplifiedinwhatone

oftheexpertsaid:

“Youhaveconsideredtwoveryimportantcomponentsofmotivation.Theonethat

comesfromwithinandtheonethatIcandevelopfromeitherwhatIseeorthatcan

hopefullyfeedmyinnermotivation.”

Theexpertcontinuedbysayingthatusingbothtypesofmotivationwouldleadtoincreased

engagement(“insomethingthatisinterestingandfun”),aswellasallowinguserstogrow(“so

thattheirinnerselfcanbetrulymotivatedandkeepgoodhealthandtheactivitiesofself-

management”).Thus,nochangesweremadetothemotivationguidelines.

Sustainability

Thecommonviewpointamongtheexpertswasthatthecontentofthisguidelineis

comprehensiveandclear.Theyexpressedastrongviewthatthisthemeisaveryimportantpartof

theguideline.Expertsindicatedtheimportanceofremindingtheusertousetheapporto

performtheself-managementactivitiesthroughusingtriggers,whichcouldbeintheformoftext

orsounds.

Thestorylineandthemeelementsreceivedthemostattention.Oneexpertexpressedenthusiasm

aboutthestorylineelementbysaying:

“Itisveryimportant-Ireallylikethiselementinthistheme.Itisthewaytoactually

makeit[theexperienceofself-managing]meaningful.Itcreatesthecontextwhereyou

canjumpintothatworldand‘findthemagic.’”

Anotherexpertlinkedthestoryelementbacktointrinsicmotivation:

“InintrinsicmotivationyouseemlikeyouaretryingtosayIwanttopointouttopeople

thatthesethingsarebeingbeneficialtotheirhealth,whichyoumightcommunicatevia

storyoryoumightcommunicateviasomeothermeans.”

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Theexpertcontinuedsayingthatthestorylinecouldbeusedasamotivatorinthiscontext.

Anotherexpertsuggestedthatweseparatethedefinitionofthestorylineandthemes.Regarding

thedifferencebetweenthe2elements,theexpertsaidthatthethemeis:

“thebackgroundthattheusermightconnectto,tobeginwith”

whilethestoryline

“isaboutcontrollingprogressandthearctheplayertakesthroughtheirexperienceand

onthatnoteitmightbeimportanttothinkaboutwhatisthearcfortheuserforthis

system.”

Furthermore,theexpertdiscussedthewaythedeveloperwillimplementthestoryline.They

indicatedthatthedevelopermustknowtheexpectedpaththeuserwilltaketobeableto

managetheirchronicillnessinagoodway.Theyalsomustknowthepaceandthestructureofthe

storythattheyaregoingtouse.Theyalsomustconsiderthearcandstructureofthestoryand

howitwillbeconnectedtothegameinordertocreateengagement.Astheexpertsaid:

“Theideaisthatatthebeginningyougettheuserorplayersattentionandgetthem

engagedintheexperience,andthenyourelaxthatbecauseyougetimpactwiththe

userwhenyouhaveacceleration.Youhaveseriesofmicroclimaticbeforeyouhavethe

bigclimaxattheendandthenrelax.”

Moreover,thestandarddesignpracticewithregardtopacingandstorystructureshouldapply.

Self-Representation

Theexpertsagreedthatthecontentofthisguidelineiseasytounderstandandcomprehensive.

Theyagreedthatitisimportantfortheusertobeabletochangetheiravatarinawaythat

enablesthemtoidentifywiththeapp.Givingusersawaytoexpressthemselveswouldpossibly

increasetheirinvestmentintheapp.

Theautonomyelementisimportantinthecontextofself-managingchronicillnessesbecause

givingtheusercontrolovertheirchoicesandactivitiescouldleadtopatientempowerment.As

oneoftheexpertssaid:

“Howincontrolyouareinaprocess,Icanseehowthatisimportanttopeople

managingconditionswiththesekindsoftechnology.”

Socializing

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Thegeneralreactiontothisthemewasverypositiveaswell.Theexpertsthoughtthatthispartis

straightforward,easytounderstand,andcomprehensive.Asoneofthemsaid:

“Iagreewitheverythinghere,becauseIcanseethatonTwitterandsocialmediayou

therearegroupsforallchronicconditionsandpeoplegettogether,theysupporteach

othertheyunderstandtheygothroughthesamethingandtheyarethereforeach

other.”

Theexpertcontinuedtosaythatpeersupportspecificallyisveryimportantinthecontextof

gamifyingtheself-managementofchronicillnesses.Theexpertsaid:

“...Wefeelconnectedwithsomeonethatweknowunderstandsbecausewearegoing

throughthesamethinganditisdifferenttohearitfromsomeonewhoisspeakingfrom

adifferentplace.”

Self-Management

Theexpertconsensusontheguidelinesfortheself-managementthemewasthatitis

comprehensiveandclear.Asoneexpertsaid:

“Iagreewithalltheelementsandespeciallythealertelement,whichIthinkisvery

importantbecauseitisrequiredtohelpthosewhowanttolearnhowtoself-manageor

toguidethemonwhattodo.”

Regardingthealertelement,expertsagreedonitsimportanceinthecontextofself-managing.As

oneexpertsaid:

“Wetendtothinkaboutself-management‘ohyouareindependentyoudon’tneed

help’,butthisisnotthecase;itisjustthatthepersonispreparedtoknowwhoto

contactandhowtofollowthenecessarystepstofollowtokeeptheconditionunder

control.Soanalertisveryimportant.”

Oneexpertlinkedthisthemetotheesteemthemebysaying:

“Youareessentiallytalkingaboutcommunicatingtwotypesofinformation.Oneisabout

thestatusofthesystemandthe“game”anditiscoveredbytheEsteemtheme.The

otheroneabouttheunderlyingstatusoftheirillness.”

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5.5 Study2:FocusGroupInterviews

Inthissection,thefocusgroupinterviewsdesignandprocessisdiscussed.Thenthefindingsof

thestudyarepresented.

5.5.1 FocusGroupInterviewsDesignandProcess

Inordertoavoidcreatingasetofguidelinesfromtheperspectivesofresearchersalone,itwas

essentialtotaketheopinionsoftheintendedusersintoconsideration,i.e.thedevelopers.The

focusgroupmethodwaschosentogatherinformationandtheopinionsofdevelopersonthe

clarity,usefulness,andeaseofimplementationoftheguidelines.Inparticular,thefocusgroup

interviewswereconductedtofindouttheclarityofthecontentoftheguidelines(suchas

definition,goals,etc.)forthedevelopers.Also,tofindoutifthedevelopersthoughtthatthe

guidelinescouldpotentiallyhelpthemincreatinggamifiedappsfortheself-managementof

chronicillnessesandtoassessifdevelopersthoughtthatimplementingTheWheelofSukrintoan

appwouldbefeasibleandiftheycouldthinkofpracticalwaystogamifyappsbasedonthe

guidelines.

TheselecteddevelopersarePhDresearchersandpostdoctoralresearchersincomputerscience,

Webtechnology,andsoftwareengineeringattheUniversityofSouthampton.Whenacandidate

participantwasapproached,theywereaskediftheyhadexperienceindevelopingappstobe

includedinthestudy,regardlessoftheirlevel.Twentyexpertswereapproachedbyemailandin

personandaskedtotakepartinthestudy;fifteenofthemconfirmedthattheywould.

Inthisstudy,fivefocusgroupswereconducted.Eachoneconsistedoftwotofourdevelopers,

resultinginfifteenparticipants.Afterconductingthefivefocusgroupinterviews,thepointof

saturationwasreachedwherenonewdatawerefound.Themaincriterionforchoosingthe

samplewasthattheyhaveexperienceindevelopingapplications(Tessmer,1993).Thesample

alsoconsistedofdeveloperswithexpertiseinsoftwaresustainability.

Eachfocusgroupsessionstartedwithgivingthedevelopersanoverviewoftheresearch,andwhy

theywerechosentoparticipate.Next,developerswerepresentedwiththeguidelinestoreadand

understandthem.Afterreadingeachtheme,thedeveloperswereaskedtoratetheguidelinesfor

thatthemebasedonthreeaspects:clarity,usefulness,andeaseofimplementation.Inparticular,

theywereaskedtochooseascorefrom1to9(1beingnegativeand9beingpositive).Then,they

wereaskedtodiscusstheguidelinesandraiseanyconcernsaboutthecontent.

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Attheendofeachfocusgroupsession,snap-shotsofanapplicationfortheself-managementof

diabetes,whichwasarbitrarilychosenanddoesnotcontainanygamification,werepresentedto

thedevelopers.Theywereaskedtousetheguidelinestosuggestimprovementtotheapp.

Thefocusgroupinterviewslasted60to90minuteseach.Theinterviewswereaudiorecorded

afterobtainingtheconsentoftheparticipants.Theinterviewsweretranscribed,andanalysed

basedonthethemesoftheframework.

5.5.2 FocusGroupInterviewsFindings

Inthissection,wepresentthefindingsofthefocusgroupdiscussionswithdevelopers.As

explainedearlier,thedeveloperswerehandedthesetofguidelinesandsnapshotsofanon-

gamifiedappforself-managingdiabetes.Theywereaskedtoreadtheguidelinesanddiscuss

themtheme-by-theme.Afterreadingeachtheme,theywereaskedtorateitfrom0to9(0the

lowestratingand9thehighest)intermsofclarity,usefulness,andeaseofimplementation.The

averagescoresofeachthemecontainedintheguidelineareshowninTable2.Itshouldbenoted

thatthesescoresreflecttheopinionsofthedevelopersontheguidelines.Clearly,theresults

showaverypositiveopiniontowardthem.

Table5-2ScoreTable(Ratingsfrom0-9)

Clarity Usefulness Easeof

implementation

Fun 7.5 7.7 7.1

Esteem 7.1 7.3 7.1

Growth 7.1 7.7 7.3

Motivation 6.1 7.7 5.5

Sustainability 7.8 8.1 7.5

Self-representation 7.5 7.8 7.9

Socializing 8.1 7.9 8.0

Self-management 8.3 8.2 8.4

Thefindingsofthefocusgroupinterviewsweredividedintoeightgroupsfollowingtheeight

themesofTheWheelofSukr.

Fun

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Oneofdevelopersaid:

“IhaveverylittlebackgroundingamificationbutnowIcanreadthisandunderstand

whattheseelementsare,andwhatIamsupposedtodo.”

Anotherdevelopersaid:

“Yourguidelinesadaptwithwhatexistnow[intheareaofWebandappdevelopment]

anditisveryclear....ourlivesdependoncollectingpointsandrewards.”

ItwasevidentthattheFunthemeelementsareveryclearasmanyofthedevelopersmanagedto

relatetheseelementstoappsthattheyhavebeenusing,inparticularhealthandfitnessappsin

whichgamificationaspectshavebeenused.

Thenotionofsharingachievementsbetweenusers,whichwasmentionedintheApplication

sectionofthefuntheme,neededsomeclarification.Inparticular,theresearcherexplainedthat

theachievementelementdoesnotinvolvesharingprivatemedicalresults.Instead,itconcerns

sharingthepointscollectedorbadgesasaresultofgoodself-managementpractices.

Consequently,theguidelineswereupdatedwiththisclarification.

Overallthedevelopersweresatisfiedwiththefuntheme.Onedevelopersaid:

“Fromadeveloper’spointofview,Ithinktheseprovidegoodguidelines;thingstokeep

inmindwhiledesigningyourapp.”

Anothersaid:

“Theguidelinesaregeneralenoughtohelpdeveloperscreatedifferentgamifiedapps.”

Esteem

Theclarityofthethemeisexemplifiedbywhatonedeveloperstated:

“Ithinkitisclearanditgoeswellwiththefuntheme.”

However,onepointthatneededclarificationistheleaderboard.Theinterviewerexplainedthatit

isnotcalculatedbasedontestresults(e.g.,thebloodglucosetestresults),butitisbasedonthe

activitiesofself-management(thetasksrequired)(e.g.,thenumberoftimestheuserentered

theirtestresultsorthenumberoftimestheuserachievedtheirgoals).Asindicatedinthe

guidelines,thedevelopercanaddtothisorchangetheleaderboardmechanismaslongasthey

keepinmindthesensitivityofthedatacollectedanddonotcompareusersbasedontheirtest

entries(e.g.,theirbloodglucoselevels).

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Growth

Onedevelopersaid:

“Thisisformequiteusefulandthedescriptionisclear”

ThisisinaccordancewiththegeneralimpressionoftheotherdevelopersascanbeseeninTable

2.Onepointthatneededclarificationisthatfeedbackdoesnotmeanfeedbackfromotherusers;

thistypeoffeedbackcouldbeapartofthesocializingthemeasamatterofpeersupport.The

feedbackreferredtohereisfromtheappitself.Forexample,whentheuserlogstheirtestresults,

adoctorcharacteroranothercharactercanshowupandreassuretheuserthattheyaredoinga

goodjob,oritcouldsimplybeanotificationthatappearscontainingarelevantmessage.

Motivation

Next,eventhoughtheeaseofimplementationforthemotivationthemewaslowcomparedto

theotherthemes,developersmanagedtocomeupwithanumberofexamplesonhowto

implementintrinsicandextrinsicmotivationsaftersomediscussion.Oneoftheexamplesgivenby

developerswasaskingtheuserabouttheirfavouriteanimal,whichwouldbetheircompanion

throughouttheapp.Theonlywaytotakecareoftheircompanionisbyloggingtheirdataand

performingtheself-managementtasks.Anotherexamplewastoprovideuserswithtipsand

informationonhowtomaintainahealthylifestyle,whichcouldenhancetheirmotivation.

Overall,developersfoundtheguidelinesofthemotivationthemeuseful.Asonedevelopersaid:

“Theinformationisusefulforthedeveloperthattherearetwotypesofmotivationthat

theycanimplement.”

Sustainability

Thedevelopersmentionedthechallengeanddifficultyofcarryingouttheelementsofthe

sustainabilitythemeandhowtheguidelinesarehelpful.Theythoughtthatiftheseelementswere

includedinsomeoftheappstheyhaveused,theywouldhavecontinuedusingthem.

Thetriggerandnudgeelementsneededsomeclarification,asoneofthedeveloperscouldnot

distinguishbetweenthetwo.Thus,thedescriptionofbothelementsintheguidelinewasedited

toeliminateanyfuturemisconceptions.Thetriggerelementoccurswhenapersonisremindedto

performbehaviourthroughvisualoraudiocues.Ontheotherhand,thenudgeelementispositive

reinforcementandanindirectsignaltowardanunenforcedact.

Thesatisfactionwiththisthemeissummarizedwiththefollowingstatement:

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“Thedescriptionofthestorylineandthemeisveryhelpfultome.Andforthenudgeitis

usefulbecauseeverytimetheuserusestheapptheygettoentertheirglucoselevel,

whichcanhelptheuserslogeverythingdailyandveryintuitively.Alsotheremindersare

usefulforusers,soiftheyforgottouseittheywillremember.SoIthinkthisisvery

clear!”

Self-Representation

Inthissection,theabilityelementneededsomeclarification.Thus,itwasclarifiedtoshowthat

whendesigningtasksorchallenges,thedevelopershouldconsiderthevariedabilitiesofusers.

Forinstance,someusersmightfinditdifficulttoperformcertaintasks.Therefore,simplifyingthe

tasksishighlyrecommended.Onusingavatars,onedevelopersaid:

“Itcreatesalinkbetweentheuserandappandletstheuserengagewiththeapp

more.”

Overall,developersagreedthattheself-representationpartisclear(seeTable2).Asoneofthe

developerssaid:

“ItcompletelyconnectswithwhatwehavebeendiscussingandIknowhowto

implementeverythinghere.”

Socializing

Atthisstagesomedevelopersstartedtoseeconnectionsbetweenthedifferentthemesofthe

wholesetofguidelines.Asonedeveloperstated:

“Thishelpsmeunderstandthefunthemeandesteemthemebetterbecauseitmeans

peoplewillsharetheirachievementssotheycanengagemorewiththeapp.”

Otherdeveloperssupportedthenotionthatthesocialaspectenablesuserstonotonlysharetheir

achievementwiththeirpeersbutalsowithfamilyandfriends.Thiswassummarizedinthe

followingstatement:

“Itisusefultobeconnectedwithfamily,andtheycanseeyourprogressandtheywill

commentpositivelyandthenyouwillfeelbetter.”

Overall,thedevelopersdidnotraiseanyissuesregardingthisthemeandhencenomodifications

weremade.

Self-Management

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Oneofthedeveloperssaid:

“Thepointsarequiteclear,andIliketheideaofaddingthevisualizationaspectbecause

obviouslytheycanclearlyseethetrends.”

Anotherdeveloperstated:

“Ithinkthisisimportant.Thelogbookwillhelpuserschecktheirprogress,andthe

visualizationwouldgiveusersastraightforwardimpressionontheirprogress.”

Theconceptscontainedinthisthemewerefamiliartomanyofthedevelopers,assomeofthem

expressedthattheyhaveappliedmanyofitselementsindevelopingprojectsthattheyhave

workedonpreviously.Noclarificationwasrequiredforthistheme,andhencethecontentofthe

guidelineshasnotbeenchanged.

Finally,attheendofeachfocusgroupsessiondeveloperswerepresentedwiththesnapshotsofa

non-gamifiedself-managementappfordiabetes.Theywerethenaskediftheycouldusethe

guidelinestosuggestwaystoimplementgamificationinthisapp.Itwasnotedthatdevelopers

wereconfidentthattheguidelineswouldenablethemtotransformanon-gamifiedappintoa

gamifiedone.Thisincludesthosedeveloperswhohadsomemisconceptionsonsomeofthe

elements(beforebeingclarifiedbytheinterviewer).

5.6 Discussion

Theuseofgamificationforhealthcarepurposespresentsatoolthatcouldenhancepatientself-

care(Mccallum,2012;Primacketal.,2012;Kingetal.,2013).Gamificationcouldbethoughtofas

amotivationaltoolandincorporatesanumberofbehaviouralchangemethods(Cugelman,2013;

Hamari,KoivistoandSarsa,2014;El-Hillyetal.,2016).Inthecontextoftheself-managementof

chronicillnesses,gamificationcouldturndailytasksofself-managinganillnessintoarewarding

andengagingactivity(Kingetal.,2013).However,asmentionedintheintroduction,thereisa

shortageinspecificframeworksanddeveloperguidelinesinthisarea.Currentimplementationsof

gamificationinhealthcaredonotfollowanyspecificguidelines(SeabornandFels,2014).Hence,

thisworkfillsthegapbyprovidingasetofguidelinesfordevelopers.

Beforethecreationoftheguidelinesaframeworkfortheself-managementofchronicillnesses

(TheWheelofSukr)wasintroduced(seeCh.4).Theframeworkcombinesgamificationwith

behaviourchangemethods,andtheself-managementofchronicillnesses.Itfilledagapthat

existedintheliterature.TheframeworkwasdiscussedwithexpertsasmentionedinCh.4.The

expertssupportedtheneedfortheincorporationofgamificationinthisareainthewaypresented

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intheframework.Thisisbecauseofthepotentialbenefitsthatgamificationcanhaveontheself-

managementhabitsofindividualswithdiabetes.Moreover,theconceptsoftheframeworkwere

supportedbyindividualswithdiabetes(basedinSaudiArabia),andthestudy(inCh.4)showed

thattheframeworkcanpotentiallysatisfytheirneeds.However,inordertoenabledevelopersto

accuratelyincorporatetheconceptsoftheframeworkintoanapp,itwasessentialtocreateaset

ofdeveloperguidelinesthatreflecttheframeworkinaclear,comprehensive,easytouseway.

Inthischapter,wepresentedasetofguidelinesfordeveloperstogamifytheself-managementof

chronicillnesses.Theguidelinesarebasedonthe8themesofTheWheelofSukrframeworkalong

withtheirelements.Themethodschoseninthisstudyareexpertinterviewsandfocusgroup

sessionswithdevelopers.Interviewswerechosentoenablein-depthdiscussionandassessment

oftheguidelines(KaplowitzandHoehn,2001).Theintervieweescamefromdifferent,but

relevant,backgrounds.Thisputstheminapositiontogivevitalfeedbackontheguidelinesbased

ontheirexpertise.Likewise,theinputfromdeveloperswasnecessarytoensurethatthetarget

groupoftheguidelines(i.e.,developers)cancomprehendthecontentoftheguidelinesand

indicatesthattheyareusefulandeasytoworkwith.Toaccommodatethedifferentlevelsand

backgroundsofthesedevelopers,afocusgroupmethodwasmostsuitable(Asbury,1995).

Indeed,thedevelopersmanagedtodiscusstheguidelinesamongthemselvesandanswereach

other’sconcernsandquestions.

Thefindingsofbothstudies(theexpertinterviews,andthedeveloperfocusgroupsessions)show

thatthereisagreatdealofsupporttothesetofguidelinesfrombothexpertsanddevelopers.

Theexpertinterviewsensuredthatthecontentoftheguidelinesreflecttheframeworkandare

comprehensiveandsound.Additionally,thefocusgroupsessionswithdevelopers,whoarethe

enduseroftheguidelines,showedthattheyagreeontheontheclarity,usefulness,andeaseof

implementationoftheguidelines.Itisworthwhilementioningthatthevalidationoftheguidelines

wascarriedoutintwosequentialsteps.Theguidelineswereupdatedonthelightofthefindings

ofthefirststudy,andthenconfirmedbythesecondstudy.

Thein-depthdiscussionswithexpertsfromacademiainthefieldsofgameandappdesignand

userexperienceindicatedthattheguidelinescoveradequateinformation.Theyalsonotedthat

theguidelineswouldbeusefulfordevelopersofself-managementapps.Moreover,theexperts

discussedtheimportanceoftheelementsintheguidelines.Inparticular,theexpertsagreedthat

thethemesencapsulateimportantpartsofthecreationofagamifiedexperience.Theyagreed

thateventhoughthereareothercoredynamics,PBL,competitionsandchallengesarerelevantin

theself-managementofchronicillnesses,whileothersmightnotbeduetothesensitivityofthe

subject.Furthermore,therewasanagreementamongexpertsthattheseelementswouldenable

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developerstocreateappsthatbringapositivespinonthedailyself-managementtasksofa

chronicillnesses.

Furthermore,thefocusgroupsessionswithdevelopersshowedthattheguidelinesmaywellbe

usefulincreatinggamifiedself-managementappsforchronicillnesses.Theconsensusamongst

developerswasthattheguidelinesareclear,easytounderstand,andachievable.Thiswas

evidentwhendeveloperswereshownaself-managementappthatdoesnotincludegamification

elementsandtheymanagedtousetheguidelinestosuggestspecificwaystoimplement

gamificationintheapp.Moreover,theywereabletodiscussthethemesoftheguidelinesand

drawsimilaritiesbetweenthemandsomeoftheappsthattheyuse.Thisindicatestheclarityand

easeofuseofthesetofguidelines.Additionally,thedevelopersfoundthattheguidelinesare

generalenoughtoenablethemtoincorporategamificationintoself-managementappsfor

differentchronicillnesses.Thisfillsthegapintheliteratureregardingthelackofguidelinesinthis

area.

Overall,therewasanagreementfromparticipantsinbothstudiesthatsuchguidelinesare

neededinthisarea.Thisisalsosupportedbytheliteraturefindings,wheresomeresearchers

arguedthatthecurrentimplementationsofgamificationinhealthcaredonotadheretostandard

guidelines(Lister,West,Cannon,SaxandBordegard,2014).Additionally,itwassuggestedthat

gamifiedappsdonotreflectthetheoreticalframeworksandapproachesfoundintheliterature

(SeabornandFels,2014).Intheirpaper,SeabornandFels(2014)arguethattheoreticalworkis

notstudiedempiricallyandthattheappsandsystemsthatappliedsomeofthetheoriesdidnot

testtheirvalidityempirically.However,giventhatgamificationisstillconsideredtobeatanearly

stageintermsofbeingappliedtotheself-managementofchronicillnesses,theremustbea

startingpoint,andatheoreticalframeworkalongwithcomprehensiveguidelinesisneeded.

Finally,itisworthmentioningthatNielsen(1994)pointedoutthatdeveloperscouldfeel

intimidatedbylongguidelines(1000rulesforexample),soitwasimportanttotaketheopinions

ofthedevelopersontheguidelinesandwhethertheyfinditusefulandclear.Thedevelopers

agreedthatthesetofguidelinesisconciseandisnotintimidating.

5.7 Summary

Thischapterpresentedguidelinesforthedevelopmentofgamifiedself-managementappsand

systemforchronicillnesses.TheWheelofSukrframeworkwastranslatedintoasetofguidelines

fordevelopers.Thesetofguidelinescontainedeightthemes:fun,motivation,growth,self-

representation,self-management,sustainability,esteem,andsocialising.Eachthemeofthe

guidelineswasdividedinto5parts:thethemeanditscorrespondingelements(fromTheWheel

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ofSukr),definition,goal,description,andapplication.Theguidelinesweredesignedsuchthat

theyreflecttheframeworkaccurately,comprehensively,andbeclear,easytoimplement,and

useful.

Thesetofguidelineswasvalidatedusingamulti-methodapproachthattriangulatedexpert

interviewsandfocusgroupinterviewssequentially.Thecontentoftheguidelineswasdiscussedin

depthwithexpertsfromacademiausingsemi-structuredinterviews.Theexpertshadexperience

intheareasofgamedevelopment,userexperience,andgamification.Thefindingsfromthe

expertinterviewssuggestedthattheguidelinecontentiscomprehensiveandreflectstheWheel

ofSukr.Moreover,theexpertsgavesuggestionstoenhancetheguidelinesandthoseweretaken

intoconsiderationtoupdatethem.Therewasconsensusfromtheexpertsthattheguidelinesare

important.

Afterthat,theupdatedversionoftheguidelineswasdiscussedwithdevelopersinthefocusgroup

interviewsessionstoensuretheclarity,usefulness,andeaseofimplementationoftheguidelines.

Thefindingsofthefocusgroupinterviewsshowedthatthereisanoverwhelmingagreement

amongthedevelopersthattheguidelinesareuseful,easytoimplement,clear,andcanbeapplied

tocreateself-managementgamificationapps.

Providingthevalidatedsetofguidelinesfillsthegapintheliteratureandsetsthestageforfuture

studies.

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Chapter6: Conclusions

Inthisthesis,theconceptofgamification,whichborrowsfromgamesbutisnotagamebyitself,

wasaddressed.Gamificationusesrewards,theurgeforrecognition,andtheneedforinstant

positivefeedbackinhumannaturetoenhancemotivation,increaseengagement,andpromote

changeinbehaviour.Asdiscussedintheliteraturereview,gamificationhasbeenreceivingagreat

dealofattentioninbothindustryandacademia,andithasbeenappliedinmanyfieldsincluding

healthcare.However,thereisstillalackofframeworksandguidelinesforitsimplementationin

theself-managementofchronicillnesses.

Diabetesisoneofthemostcommonchronicillnessinmanycountries.Self-managingdiabetesisa

continuouseffortthataimsatmanagingandsustainingtheadvisedlevelofbloodglucoseand

avoidingcomplicationsinordertoleadahealthylife.Thenatureoftheself-managementof

diabetescouldcreateastrainonindividualswithdiabetes.Monitoringbloodglucose,adheringto

medication(insulin),maintainingahealthydiet,managingsocialpressures,andotherchallenges

ofself-managementcouldhaveatollondiabeticindividuals.

Incorporatinggamificationintotheself-managementofdiabetescouldhavepositiveimpactson

individualslivingwiththeillness.Gameelementsandthepsychologybehindgamificationcould

helptoincreasethemotivationandengagementofindividualswithdiabetesintheirdailyself-

managementprocess.Itcouldalsoturnthetediousandrepetitivetasksofself-managementinto

arewardingandengagingactivity.

Moreover,theliteraturereviewcoveredthethreemainareasofresearch:gamification,the

psychologybehindit,andtheself-managementofdiabetes.Thegapintheliteraturewas

identifiedasthelackofframeworksandguidelinesforthegamificationoftheself-management

ofchronicillnesses.Thefirstaimofthethesiswastoprovideanappropriateframeworkforthe

gamificationoftheself-managementofdiabetes.Thesecondaimofthethesisinvolveddesigning

asetofguidelinesfordeveloperswhowanttoincorporategamificationinappsfortheself-

managementofchronicillnesses.

Thefirstpartofthethesissetouttodevelopaframeworkthatappliestheconceptofgamification

intheself-managementofchronicillnesses,specificallydiabetes.Basedontheliteraturereview

findings,twenty-eightelementsweresynthesisedintoeightthemestocreatetheframework:The

WheelofSukr.Tothebestofourknowledge,thisisthefirstframeworkthatistargetedtowards

theself-managementofchronicillnesses.Itcombinesgamification,behaviourchangemethods,

andself-managementpractices.

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TheWheelofSukrconsistsofeightthemes,eachencompassinganumberofelements:

• Theself-managementtheme,whichincludesthefollowingelements:logbook,

visualisationofdata,andtrendalerts.

• Thesocialisingtheme,whichincludesthefollowingelements:community,socialmedia,

peer-support,andsharing.

• Theself-representationtheme,whichincludesthefollowingelements:avatars,

autonomy,ability,andpurpose.

• Thefuntheme,whichincludesthefollowingelements:badges,points,challenges,and

competition.

• Theesteemtheme,whichincludesthefollowingelements:leaderboards,levels,progress

bar,andreputation.

• Themotivationtheme,whichincludesthefollowingelements:intrinsicandextrinsic

motivation.

• Thesustainabilitytheme,whichincludesthefollowingelements:trigger,flow,storyline

andthemes,andnudge.

• Thegrowththeme,whichincludesthefollowingelements:feedback,achievinggoals,and

babysteps(tinyhabits).

TheWheelofSukrframeworkisillustratedinFigure4-3.Theframeworkisintheshapeofa

wheel,whichwaschoseninordertoreflecttheimportanceofallofthethemestogether.The

themesandtheirelementscombinedcreateagamifiedenvironmentthatcouldimprovetheself-

managementexperienceofindividualswithchronicillnessesandmakeitaneasierandmore

enjoyableactivity.

ThevalidationprocessofTheWheelofSukrwasdonethroughamixed-methodapproach.This

consistedoftwostudies:thefirstinvolvedexpertinterviewsandthesecondtooktheformofa

self-administeredquestionnaire.

Inthefirststudy,expertinterviewswerecarriedoutwitheightexpertstovalidatetheproposed

frameworkfromthreedifferentperspectivesthatreflecttheareasofresearch(i.e.gamification,

behaviourchange,andself-managementofdiabetes).Theexpertsinthestudywerecarefully

selectedfromthreemainfields:

• DiabetesdoctorsandeducatorsbasedinSaudiArabia.

• PsychologistsandpsychiatristsbasedinSaudiArabia.

• GamificationexpertsfromtheUniversityofSouthampton.

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Sincethisthesisisconcernedwiththegamificationoftheself-managementofchronicillnesses,it

wasnecessarytointerviewexpertsfromthemedicalfield.Thisisbecausetheyunderstandwhat

isneededtoself-managetheillnessproperly.Theyalsohaveanimmediateunderstandingofthe

strugglesthatindividualsfacelivingwithdiabetes(theirpatients)intermsofself-managingthe

illness.Moreover,thepsychiatristsandpsychologistswouldunderstandthepsychologicalsideof

gamificationandtheframeworkinvolvingtheuseofmotivationandbehaviourmethods,andthe

importanceofpeer-support.

ThesecondstudyconductedtovalidateTheWheelofSukrwasanonlineself-administered

questionnaire.ThequestionnairewasfilledinbyindividualswithdiabetesbasedinSaudiArabia.

ThequestionnaireconsistedofaLikertscaleincludingthirty-fourstatementsthatcoverthe

conceptsbehindtheframework’sthemes.

Forty-twoindividualsparticipatedinthestudy.However,thehighstigmaarounddiabetesinSaudi

Arabiacouldhaveresultedinmanypeoplenotwillingtotalkabouttheirillness,anditwas

difficulttoreachalargernumberofparticipants.TheexistenceofstigmaarounddiabetesinSaudi

Arabiawassupportedbythemedicalexpertsinthestudy,whoindicatedthatindividualswith

diabetesdonotusuallyparticipateingroupeventsfordiabetes.Theyalsoindicatedthatstigma

influencestheirdailyself-managementnegatively.

Nevertheless,itwasessentialtoconductthisquestionnaireandtakeintoaccounttheviewsofthe

targetaudienceonthegamificationoftheself-managementofchronicillnesses.Itwasalso

importanttoundertaketheinterviewswiththeexpertsfromthethreegroupsasindicatedearlier.

Bothstudiescombinedprovidedawell-roundedviewregardingtheuseofgamificationinthis

areaandalsovalidatedtheframework.

Theinterviewsweretranscribedandanalysedusingthematicanalysis,whilethequestionnaire

resultswereanalysedusingthestatisticalonesamplet-test(2-tail)method.Theresultsofboth

studiesvalidatedthethemesoftheframework.Thefindingsofbothstudiessuggestthatthereis

ageneralacceptanceofthenotionofgamifyingtheself-managementofdiabetes.Thestudies

alsoshowthatthethemesofTheWheelofSukrcouldcontributetoimprovingtheexperienceof

theself-managementofchronicillnessesforindividualswithdiabetes.Thisframeworksetthe

stageforcreatingspecificguidelinesforgamificationinthisarea,whichisthesecondaimofthe

thesis.

Inparticular,afterthevalidationofTheWheelofSukrframework,itwastranslatedintoasetof

guidelinesfordeveloperstoaidtheminthedevelopmentofgamifiedself-managementappsand

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systemsforchronicillnesses.Theframeworkconsistedofeightguidelinesbasedonthethemesof

TheWheelofSukr.Eachoneoftheguidelineswasdividedintofiveparts:

• Theme:ageneralconstructcontainingelementsthatsharethesamegoal.

• Definition:Thegeneralideaofthethemeisdefined.

• Goal:Thepurposeofthethemeanditselementsarestated.

• Description:Thethemeanditselementsareelaborated.

• Application:Thethemeistranslatedintopointerstohelpinitsimplementation.

Thesetofguidelinesweredesignedinawaytoenabledeveloperstotailorthethemestotheir

individualprojects(i.e.thegoals,objectives,andtheusersoftheirapp).Forexample,developers

couldimplementdifferenttypesofbadgesandpointsmoresowhentheyaretargetingyoung

usersthanwhentargetingadults.

Thevalidationofthesetofguidelineswascarriedoutusingamulti-methodapproach.Itconsisted

oftwosequentialstudies:expertinterviewsandfocusgroupinterviews.

Inthefirststudy,thecontentoftheguidelineswasdiscussedindepthwithsixexpertsfrom

academiausingsemi-structuredinterviews.Theexpertswereselectedfromtheresearchstaffat

theUniversityofSouthampton.Theyareexperiencedintheareasofgamedevelopment,user

experience,andgamification.Theinterviewswereconductedasaformativeevaluationoftheset

ofguidelinestoensureitsaccuracy,andtoensurethatitrepresentstheframeworkaccurately

andcomprehensively.Eachinterviewlasted60minutesandwereaudio-recorded.Theinterviews

werethentranscribedandanalysedusingthematicanalysis.

Thefindingsoftheexpertinterviewssuggestthatthesetofguidelinesiscomprehensiveand

reflectsTheWheelofSukr.Moreover,theexpertsgavesuggestionstoenhancetheguidelinesand

theseweretakenintoconsiderationwhenupdatingtheguidelines.Theinsightoftheexpertswas

valuablegiventhattheyareveryexperiencedandknownresearcherswhocontributetothearea

ofgames.Theirsupporttotheformulationofthesetofguidelinesshowsthatitisneededand

important.

Aftervalidatingthesetofguidelinesusingtheexpertinterviews,itwasanaturalsteptovalidate

itusinginterviewswithdevelopers.Itisworthmentioningthatthesetofguidelineswasdesigned

withdevelopersinmind.Thus,itwasimportanttoconsultthedevelopers(i.e.theendusersof

theguidelines)andchecktheclarity,usefulness,andeaseofimplementationofthesetof

guidelines.

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Afterthefirststudy(expertinterviews),thesetofguidelineswasmodifiedbasedontheinputof

theexperts.Thesecondstudythenusedthenewversionoftheguidelines.Inthesecondstudy,

fifteendeveloperswereinterviewedinfivefocusgroupsessionstoensuretheclarity,usefulness,

andeaseofimplementationofthesetofguidelines.Thefocusgroupsessionswerearound90

minuteseach.Theinterviewswereaudio-recordedtobesubsequentlytranscribedandthen

analysedusingthematicanalysis.

Thewerepresentedwiththesetofguidelinesofandsnapshotsofagenericnon-gamifiedappfor

self-managingdiabetes(whichwaschosenrandomly).Thedevelopersreadtheguidelinesduring

theinterviewanddiscussedthemtheme-by-theme.Theywerealsoaskedtorateeachtheme

from0to9(0beingthelowestratingand9thehighest)intermsofclarity,usefulness,andease

ofimplementation.Thefindingsshowedthatthereisanoverwhelmingagreementbetween

developersthattheguidelinesareuseful,easytoimplement,clear,andcanbeappliedtocreate

self-managementgamificationapps.

Thedeveloperswerealsopresentedwithsnapshotsofagenericnon-gamifiedappforself-

managingdiabetes(whichwaschosenrandomly).Thedeveloperswereaskedtothinkofwaysto

gamifythegenericappafterreadingtheguidelinesforallthethemes.Thiswascarriedoutto

ensurethattheguidelinescanbeusedinthedevelopmentofappsthatincorporategamification

fortheself-managementofchronicillnesses.Indeed,thedevelopersdiscussedmanywaysin

whichtheycanimplementthedifferentthemesfromtheguidelines.Thisindicatesthatthesetof

guidelinesisreadytobeusedbydevelopers.

6.1 Contributions

Thisthesisaddstothegrowingbodyofresearchintheuseofgamificationinhealthcare.Itfillsthe

gapinliteratureregardinggamificationfortheself-managementofchronicillnesses.Thethesis

consistedoftwomajorcontributions:

• Avalidatedframeworkforgamifyingtheself-managementofchronicillnessescalledThe

WheelofSukrframework.

• Avalidatedsetofguidelinesfordevelopersbasedonthevalidatedframeworktoaid

developersincreatinggamifiedappsfortheself-managementofchronicillnesses.

Tothebestofourknowledge,thisisthefirststudytoprovideaframeworkandguidelinesforthis

specificarea.Moreover,intheprocessofresearchinganddesigningthefirstcontributionthe

researcherprovided:

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• Areviewontheliteratureofgamificationinhealthcareandthelinksbetweentheareasof

gamification,behaviourchange,andtheself-managementofchronicillnesses.

• Establishedagapintheliteraturewithregardstoframeworksandguidelinesfortheuse

ofgamificationintheself-managementofchronicillnesses.

• Identifiedtwentyelementsfromtheaboveareasandsynthesisedthemintoeightthemes

tocreatetheframework:TheWheelofSukr.

• Validatedtheframeworkwithexpertsinmedicine,psychologyandpsychiatry,and

gamificationandgamesexpertise,aswellas,individualswithdiabetes.

Moreover,thefactthatitwaspositivelyviewedbytheseexpertsandthetargetusers(i.e.

individualswithdiabetes)isoneofthestrengthsofthisstudy.Thefindingsofboththeinterviews

andquestionnairestrengthentheideathatgamificationcouldbenefitindividualswithchronic

illnessesintheirself-managementprocess.

Intheprocessofresearchinganddesigningthesecondcontribution,theresearcher:

• Recognisedtheneedforguidelinesforthedevelopmentofgamifiedself-management

appsforchronicillnesses.

• Translatedtheframeworkintoasetofconciseandclearguidelinesfordevelopers.

• Validatedthesetofguidelineswithexpertsfromacademiaandwithdevelopers.

Thesetofguidelinescanbeusedbydeveloperstocreateself-managementappsfordiabetesand

otherchronicillnesses.Suchappswillproperlyimplementgamificationandmeetthe

expectationsofmedicaldoctorsandindividualswithchronicillnesses.

6.2 Futurework

Theaimofthisthesiswastofillthegapintheliteratureregardingtheuseofgamificationforthe

purposeofself-managingchronic.Particularly,identifyingthekeyelementsfromtheliteratureof

gamification,behaviourchange,andself-managementofchronicillnessesanddevelopinga

frameworkanddeveloperguidelines.ThethesispresentedandvalidatedTheWheelofSukr

frameworkandadevelopersetofguidelinesforthegamificationofself-managementofchronic

illnesseswithafocusondiabetes.Theframeworkandthesetofguidelineswerevalidatedbya

widerangeofstakeholders.Theframeworkwasvalidatedbymedicaldoctors(including

endocrinologistsandpsychiatrists),gameandgamificationexpertsandpatients,whilethesetof

guidelineswerevalidatedbyacademicexpertsingames,narrative,userexperience,and

developerswhoarecomputerscientistsandsoftwareengineers.However,thereisroomand

scopetodevelopthisareaofresearchfurther.TheWheelofSukrframeworkandsetofguidelines

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canserveasabasisforfuturestudiesintheuseofgamificationintheself-managementofchronic

illnesses.Moreover,theuseofgamificationinhealthcareandspecificallypatientself-careisan

importantresearchareathatneedsfurtherinvestigation.Theinterdisciplinarynatureof

gamificationwillraisemanyquestionsthatneedtobeansweredinthefuture.

Inthisthesisweusedtheepistemologyapproachofpositivism,empiricism,andcriticism.Thisisa

commoninformationsystemsapproachofbeingpragmaticandobjective.However,thereare

differentepistemologyapproachesthatareusedinsocialsciencesandotherfields.Theseinclude

ethnographyandgroundedtheoryresearch,whicharebothappropriatestrategiesforinductive

research(asopposedtothedeductiveapproachweused).Infutureresearchtheseapproaches

canbeusedtoexploremanyareas(e.g.stigma,age,gender,cultural…etc.)inthegamificationof

self-managementofchronicillnesses.Thesestudiescanbeconductedonceagamifiedapplication

thatfollowstheWheelofSukrisdeveloped.

Nowthatwehaveshownthekeycomponentforthegamificationofself-managementofchronic

illnesses,thenextstageistodevelopaprototypeoranapplicationthatfollowsTheWheelofSukr

frameworkandthedeveloperguidelines.Thiswouldbepartofthedevelopmentphasethatwill

enableustoconductfurtherresearch.Fromthedevelopedgamifiedapplication,wewillbeable

toresearchtheuseofgamificationintheself-managementofchronicillnessesfurther.For

example,wecanascertainwhetheralltheeightthemesoftheWheelofSukrframeworkare

equallyimportantindifferentcircumstances.Thefutureresearchcanbeconductedinthe

followingareas:

-Cross-cultural:futureresearchcouldincludeinvestigatingtheimportanceandtheeffectofthe

eightthemesoftheWheelofSukrondifferentgroupsofpeople.Forexample,wecanlookatthe

useofthethemesinthedevelopedapplicationinacross-culturalsetting,andinvestigateifthere

isadifferencebasedonthecultureofeachgroup.

-Otherchronicillnesses:inthisthesiswefocusedonthecommonissuesofself-managementof

chronicillnessesandweuseddiabetesasanexample.Thiscouldbeconsideredalimitation.

However,therearecommonproblemsinmanagingchronicillnesses,whichincludekeepinga

logbook,adherencetomedication,andpeersupport.Futureworkcouldinvestigateotherchronic

illnessesandfindoutifthereisadifferenceintermsofgamifyingtheself-managementofeach

illness.Moreover,wecaninvestigatetheimportanceoftheeightthemesofTheWheelofSukrin

theself-managementofdifferentchronicillnesses.Particularly,wecanmeasuretheweightofthe

themesintheself-managementofdifferentchronicillnessesbyconductingalong-term

longitudinalexperimentandusingcontrolgroups.

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-Agegroups:aspointedoutbyoneofthemedical,thethethemesoftheframeworkmightbe

appealingtochildrenandyoungadolescents,asopposedtootherages.Futureworkcould

exploretheeffectsofthethemesoftheframework(inagamifiedapplicationforself-

management)ondifferentagegroups.Inparticular,measuringtheeffectsofgamificationin

improvingtheself-managementhabitsindifferentagegroups.

-Leaderboardsinself-managingchronicillnesses:asdiscussedinsec.5.1previousresearch(in

differentdomains)suggeststhatLeaderboardsmightdemotivatesomeusers,whileothersfindit

motivating.Thisdependsonthe“playertype”,someusersarecompetitiveandotheruserscould

besocialisers.Theeffectofthethemesoftheframeworkonthedifferenttypesofplayersshould

beinvestigatedfurtherinthespecificdomainofself-managingchronicillnesses.

-Stigma:oneoftheissuesdiscussedbythemedicalexpertswastheissueofstigmaondiabetesin

SaudiArabia,andhowitaffectstheself-managementofit.Onceanapplicationisdeveloped

basedontheWheelofSukrsetofguidelines,thisareacouldbeinvestigatedfurtherina

longitudinalstudy.Inthestudytheeffectsoftherewardingelement,peersupport,autonomyand

otherelementsoftheframeworkonthepatientandhowtheyrespondtostigma.Thiscanbe

measuredbystudyingtheindividualswiththediabetesbeforeandafterusingthegamifiedapp

thatappliestheWheelofSukrthemes.

-Bestpractices:InordertofindthestrengthsandweaknessesoftheWheelofSukr’sthemesand

elements,anempiricalstudyincorporatingthemwithinthecontextofself-managingchronic

illnessesmustbeundertaken.Thiswillhelptodeterminethebestpracticesingamifyingtheself-

managementofchronicillnesses.Forexample,thetypeofbadgesandtriggersthatmosteffective

inthisspecificareaofgamification.Also,thetypeofstorylineandthemesthatareeffectivebased

onagegrouporculture.

-Relationshipsbetweenthemes:thevalidatedframework,TheWheelofSukr,containseight

themesandeachthemeencompassesanumberofelements.Inthemixedmethodstudy,the

themesoftheframeworkwerevalidatedwithawiderangeofstakeholdersincludingmedical

experts,gamificationexpertsandindividualswithdiabetes.Itwasassumedthatthethemesof

theframeworkareofequalweightsandthefindingsofthestudiesdidnotaffectthisassumption.

Furtherstudiescouldseektocreaterelationshipsandhierarchybetweenthethemesand

elements(i.e.creatingamodel).

Gamificationinhealthcareisstillconsideredanewareaofresearch.TheWheelofSukr

frameworkanddeveloperguidelinesareamongstthefirstinthisarea.Therearemanyother

areasinhealthcarethatcouldbenefitfromgamificationframeworksandguidelinesasitisgetting

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anincreasedpopularityinbothacademiaandindustry.Wesuggestexploringtheuseof

gamificationinhealthcareeducationandawareness.Asthemedicalexpertinterviewssuggest

thattherearesomeissueswithawarenessandeducation.Futureresearchcanexplorethisarea

moreandhowgamificationcanbenefitthis.

AppendixA

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AppendixA

Thisappendixshowstheclosedandopenendedquestionsfortheexpertinterviewsforthe

validationoftheframework.

TheClosed-Questions:

• Usingarewardsystemcanbeeffectiveinmanagingdiabetes.

• Awardingusersforloggingtheirtestreadingswouldencouragethemtokeeparecordoftheir

tests.

• Visualizingtheuser’stestresultscanhelpthemindeterminingpatternsintheircondition.

• Positivemotivationcanhaveaprofoundpsychologicalimpactonthepatient’sself-

managementofdiabetes.

• Havinganonlinecommunitywherepatientscanexchangeinformationisbeneficial.

• Anonlinecommunitycanprovideemotionalandpsychologicalsupportfordiabeticpatients.

• Beinginacommunityhelpsdiabeticpatientsincopingwiththeircondition.

• Patientswillbenefitfromanonlinepeersupportsystem.

• Socialmediaandsharingsuccessfulresultsorsharingproblemsandconcernsisimportantin

thediabeticpatient’slife.

• Peersupportisanessentialelementforasuccessfullifewithdiabetes.

• Usingrewardsandgameelementscansatisfyself-esteemneeds(Maslow’sHierarchyof

Needs),whichinturnpositivelyaffecttheself-managementofdiabetes.

• Thenegativeconnotationsassociatedwithdiabetesaffectthepatient’sself-managementand

lifeoverall.

• SaudiArabianpatientswillbenefitfromtheuseofanelectroniclogbookfortheirblood

glucosetestresults.

• Tailoringtheonlineself-managementsupporttoindividualuserscancreateabondwiththe

user.Therefore,thiswillincreasetheirengagementwiththeprocessandprovidea

meaningfulexperience.

• Providingconsistentfeedbacktotheuser(abouttheglucosetestresultsandotherself-

managementskills)canleadtopersonalgrowthintermsofthemanagementofdiabetes.

Open-endedquestionsforDoctors:

1. Howimportantisittoempowerdiabeticpatientsintakingcareoftheirownlives?

2. WhatarethechallengesthattheyfaceinSaudiArabia?

AppendixA

150

3. Whatarethemostcommonproblemsthatdiabetespatientsfaceintermsofbeing

motivatedtoself-manageandself-care?

Open-endedquestionsforPsychiatristsandPsychologists:

1. Howimportantisitfordiabeticpatientstobepartofacommunity(diabeticcommunity

orhavefriendswithdiabetes)andhavepeersupport?

2. Doesrewardplayahugepartinmotivatingpatients?

3. Howimportantisittomotivatediabeticpatients?

Open-endedquestionsforGamificationandGameExperts:

1. Isself-representationcriticalintheuseofgamification?

2. Istheuseoftriggers,flow,theme,andnudgessufficientforcreatingsustainabilityina

gamifiedsystem?

Appendix

151

AppendixB

ParticipantInformationfortheexpertinterviewsstudyforthevalidationoftheguidelines

StudyTitle:Gamifyingself-managementofchronicillnesses(diabetes).

Investigator:AlaaAlmarshedi

Pleasereadthisinformationcarefullybeforedecidingtotakepartinthisresearch.Ifyouare

happytoparticipatewillbebeaskedtosignaconsentform.Yourparticipationiscompletely

voluntary.

Whatistheresearchabout?Thisisaresearchprojectthataimstoprovidedeveloperswith

guidelinestogamifytheself-managementofchronicillnesses(diabetes)basedonTheWheelof

Sukr.ThestudyissponsoredbytheSaudiGovernment.

WhyhaveIbeenchosen?Youhavebeenapproachedbecauseofyourexpertiseingame

developmentanduserexperience.

WhatwillhappentomeifItakepart?Theresearcherwillexplaintheaimofthestudyandthe

wayitwillbeconducted.Firstyouwillbeaskedifyouagreetoparticipate,ifsoyouwillbeasked

tosignaconsentform.Thenyouwillbepresentedwiththeframeworkandtheguidelines.After

that,youwillbeaskedtoansweranumberofquestions.Itwilltakeabout40-50minsintotal.

Arethereanybenefitsinmytakingpart?Thestudywilladdtocurrentknowledgeabout

gamificationinself-managementofchronicillnesses.

Arethereanyrisksinvolved?Therearenoparticularrisksassociatedwithyourparticipation.

Willmydatabeconfidential?Thedatacollectedwillbeheldonapassword-protectedcomputer,

andusedonlyin accordance with the Data Protection Act (1998).Ifyouwouldliketo

withdrawfromthestudy,pleasecontacttheinvestigator(e-mailaaa3g12@soton.ac.uk)orthe

projectsupervisor(e-mailgbw@soton.ac.uk)whowillarrangethis.

WhathappensifIchangemymind?Youmaywithdrawatanytimeandforanyreason.

Whathappensifsomethinggoeswrong?Shouldyouhaveanyconcernorcomplaint,contactme

ifpossible(investigatore-mailaaa3g12@soton.ac.uk)otherwisepleasecontacttheError!

Unknowndocumentpropertyname.Office(e-mailfpse-grad@soton.ac.uk)oranyother

authoritativebodysuchasFPSEResearchSupportOfficer,DrCeciliaDiChio,C.Di-

Chio@soton.ac.uk).

Appendix

152

ParticipantInformationforthefocusgroupinterviewsstudyforthevalidationoftheguidelines

DearParticipant,

Pleasereadthisinformationcarefullybeforedecidingtotakepartinthisresearch.Ifyouare

happytoparticipateyouwillbeaskedtosignaconsentform.

Whatistheresearchabout?Thisresearchprojectaimstoprovidedeveloperswithguidelinesto

gamifyself-managingchronicillnesses.Theguidelinesarebasedontheresearcher’sframework

“TheWheelofSukr”.

WhyhaveIbeenchosen?Youhavebeenapproachedbecauseofyourexpertiseintheresearch

ordevelopmentofseriousgames,userexperienceorappdevelopment.

WhatwillhappentomeifItakepart?Youwillbeaskedtoshowyourconsenttoparticipateinthe

studybysigningtheconsentformonthenextpage.Youwillbepartofafocusgroup(3or4in

eachgroup).Youwillbepresentedwithguidelinesandanapplicationandyouwillbeaskedaset

ofquestionsabouttheguidelinesanddiscusstheuseoftheguidelinesontheapplication.The

interviewwilltakearound50minutes.

Arethereanybenefitsinmytakingpart?Thestudywilladdtocurrentknowledgeabout

gamificationinself-managementofchronicillnesses.

Arethereanyrisksinvolved?Therearenoparticularrisksassociatedwithyourparticipation.

Willmydatabeconfidential?Thedatacollectedwillbeheldonapassword-protectedcomputer,

andusedonlyinaccordancewiththeDataProtectionAct(1998).

WhathappensifIchangemymind?Youmaywithdrawatanytimeandforanyreason.

WherecanIgetmoreinformation?Shouldyouhaveanyconcernorcomplaint,contactmeif

possible(investigatore-mailaaa3g12@soton.ac.uk)otherwisepleasecontacttheFPSEOffice(e-

mailfpse-grad@soton.ac.uk)oranyotherauthoritativebodysuchasFPSEResearchSupport

Officer,DrCeciliaDiChio,C.Di-Chio@soton.ac.uk).

Thankyouforyourtimeandparticipation.

Appendix

153

ConsentForm

1.Ihavereadandunderstoodtheparticipantinformationsheetprovidedonthepreviouspage.

2.IunderstandmyparticipationisvoluntaryandImaywithdrawatanytimeandforanyreason.

3.Bytickingthisboxyounowgiveyourfullyinformedconsenttoparticipateinthisstudy.

PleaseSignifyouagree:

Appendix

154

ParticipantInformationfortheexpertinterviewforthevalidationoftheFramework

StudyTitle:TheuseofGamificationinSelf-managementofdiabetes(inSaudiArabia)

Investigator:AlaaAlMarshedi

Please read this information carefullybeforedeciding to takepart in this research. If youare

happy to participate will be asked to sign a consent form. Your participation is completely

voluntary.

Whatistheresearchabout?ThisstudyispartofaPhDresearchontheuseofGamificationinthe

self-managementofDiabetesinSaudiArabia.

WhyhaveIbeenchosen?Youhavebeenapproachedbecauseofyourexperienceinworking

withdiabeticpatientsinSaudiArabia(ifyouareadoctor/psychologists)oryourexperiencein

gameresearchandgamificationapplication(ifyouareagame/gamificationexpert).

WhatwillhappentomeifItakepart?Whenyouchoosetotakepartinthestudy,youwillbe

shownaparticipantinformationsheetandyouwillbeaskedtosignaconsentformindicating

youragreementtobepartofthestudy.Afterthat,theinterviewerwillaskyoutofillinashort

questionnaire,andthenyouwillbeaskedanumberofquestionsrelevanttoyourfield.The

interviewwilltakeabout20-30minsintotal.

Arethereanybenefitsinmytakingpart?Thestudywilladdtothecurrentknowledgeabout

Gamificationanditsuseindiabetesselfmanagement.

Arethereanyrisksinvolved?Therearenoparticularrisksassociatedwithyourparticipation.

Willmydatabeconfidential?Thedatacollectedwillbeheldonapassword-protectedcomputer,

andusedonlyin accordance with the Data Protection Act (1998).Theinterviewwillbe

recordedforaccuracyandtherecordingwillbedestroyedoncethedataistranscribed.Any

personalinformationsuchasnameandphonenumberwillbesavedonapasswordprotected

personalorganizeranditwillbedeletedaftertheinterviewisdone.

WhathappensifIchangemymind?Youmaywithdrawatanytimeandforanyreason.

Whathappensifsomethinggoeswrong?Shouldyouhaveanyconcernorcomplaint,contactme

ifpossible(investigatore-mailaaa3g12@soton.ac.uk),otherwisepleasecontacttheDrMartina

Prude,HeadofResearchGovernance(02380595058,mad4@soton.ac.uk).

Appendix

155

ConsentForm

Please initial the box(es) if you agree with the statement(s):

Data Protection

I understand that information collected during my participation in this study is will be

stored on a password protected computer and that this information will only be used in

accordance with the Data Protection Act (1998). The DPA (1998) requires data to be

processed fairly and lawfully in accordance with the rights of participants and protected

by appropriate security.

Signature of participant……………………………………………………………..

I have read and understood the Participant Information and have

had the opportunity to ask questions about the study.

I agree to take part in this study.

I understand my participation is voluntary and I may withdraw at

any time and for any reason.

Appendix

156

AppendixC

ThetablebelowshowsthefrequenciesoftheanswersforeachquestionintheLikertscalepartof

thequestionnaireinthevalidationoftheframeworkstudy.

Strongly Agree

Agree Neutral Disagree Strongly Disagree

Q1 47.62% 42.86% 7.14% 0.00% 2.38%

Q2 35.71% 26.19% 35.71% 2.38% 0.00%

Q3 59.52% 33.33% 4.76% 2.38% 0.00%Q4 23.81% 40.48% 26.19% 7.14% 2.38%

Q5 28.57% 40.48% 23.81% 7.14% 0.00%Q6 33.33% 30.95% 16.67% 16.67% 2.38%Q7 7.14% 33.33% 23.81% 30.95% 4.76%

Q8 42.86% 35.71% 11.90% 9.52% 0.00%Q9 45.24% 33.33% 11.90% 9.52% 0.00%

Q10 35.71% 33.33% 28.57% 2.38% 0.00%Q11 30.95% 47.62% 16.67% 4.76% 0.00%

Q12 38.10% 35.71% 23.81% 2.38% 0.00%Q13 28.57% 23.81% 14.29% 26.19% 7.14%

Q14 42.86% 33.33% 21.43% 2.38% 0.00%Q15 28.57% 50.00% 11.90% 7.14% 2.38%

Q16 26.19% 42.86% 14.29% 16.67% 0.00%Q17 50.00% 40.48% 7.14% 2.38% 0.00%Q18 16.67% 40.48% 14.29% 23.81% 4.76%

Q19 30.95% 57.14% 11.90% 0.00% 0.00%Q20 16.67% 30.95% 19.05% 26.19% 7.14%

Q21 57.14% 40.48% 2.38% 0.00% 0.00%Q22 42.86% 42.86% 14.29% 0.00% 0.00%

Q23 23.81% 45.24% 16.67% 11.90% 2.38%Q24 59.52% 30.95% 7.14% 2.38% 0.00%

Q25 45.24% 52.38% 2.38% 0.00% 0.00%Q26 42.86% 54.76% 2.38% 0.00% 0.00%Q27 45.24% 40.48% 14.29% 0.00% 0.00%

Q28 30.95% 23.81% 30.95% 14.29% 0.00%Q29 7.14% 19.05% 57.14% 14.29% 2.38%

Q30 19.05% 28.57% 21.43% 28.57% 2.38%Q31 38.10% 47.62% 14.29% 0.00% 0.00%

Q32 35.71% 45.24% 9.52% 9.52% 0.00%

Appendix

157

Q33 7.14% 30.95% 33.33% 28.57% 0.00%

Q34 28.57% 40.48% 26.19% 4.76% 0.00%

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