The Role of Serious Games in the Imanagecancer Project

The role of serious games in the iManageCancer project

Stefan Hoffmann1 and Stephen Wilson2

1Promotion Software GmbH, Tübingen 72072, Germany 2University of Bedfordshire, Bedfordshire, Luton LU1 3JU, UK

Correspondence to: Stefan Hoffmann. Email: [email protected]

Abstract

Within the iManageCancer project, two serious games were developed, one for adults and one for children and adolescents. The adult’s game was developed by the University of Bedfordshire (UK), the kid’s game by Promotion Software GmbH (Germany). The aim was to support adult and young cancer patients with serious games to manage the impact of the disease on their psychological status, such as negative emotions, anxiety or depression, and motivate them to stay positive and to participate in social life [Patterson and Garwick (1994) Ann Behav Med 16 131–142; Brennan et al. (2002) J Consul Clin Psychol 70 1075–1085; Robinson et al. (2007) J Pediatr Psychol 32 400–410]. Early demonstrators showed how important it is that players understand the meaning behind the game design. Improvements in the design of the games addressed that issue. Also, technical and use case issues were found that had a significant impact on the outcome. Both games interact with the iManageCancer platform, record game results and make them available for research. Two pilots are on the way and another evaluation cycle will follow.

Keywords: serious games, childhood cancer, iManageCancer, remission Short Communication

Published: 11/07/2018 Received: 18/01/2018 ecancer 2018, 12:850 https://doi.org/10.3332/ecancer.2018.850

Copyright: © the authors; licensee ecancermedicalscience. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1 changed fromtheoriginalideatogameversionsthatwere chosenforthetwopilotswithiniManageCancerproject. process workedandhowthegames both games,howthegamedesignanddevelopment behind This articledescribestherationale cancer cellsandeliminatingthem. shooter game. as aclassical The seriousgameforkidsisimplemented for The playerisflyingwitha vesselfromlefttoright,searching included, allowingfamilyandfriendstointeractviagamemechanics withthechildren. Another problemfor children, especiallywhiletheyareinthehospital,istheirisolated situation. To improvethis, social aspects were treatment process,makethemfocusonanewtargetandpush theirmindsetinthedirectionofattackingrealenemy, thecancercells. result infeelingsofangerandhelplessness. The ideabehindthegameistomakechildrenand theirsupportersbecomeactiveplayersinthe psychological status of the target group is significant. The treatment process makes them passive participants in many ways, which may The target group for the serious game for kids are children with cancer and also their relatives and friends. The impact of the disease on the to develop his/her own avatar and his/her own city, where he/she rehearses living a well-balanced life between healthy habits and enjoyment. encourage healthyhabitsandtopromotecritical,strategicalthinking. To reachthisgoal,agamesettingwascreated, which allowstheplayer life,to these issues,makestheplayersconcentrateonthoughtsandencouragesalearningtransferfromgameinto theplayer’s may havetorethinktheirhabitsandoveralllifestyle. The ideabehindtheseriousgameforadultsistocreateathatfocuseson The targetgroupfortheseriousgameadultsiswithacancerdisease.Peopleinthishavetoreorganis e theirlivesand Both seriousgamesforiManageCancerweredevelopedseparatelywithcompletelydifferent gameplayaspectsandpurposes. Two gameswithdifferentpurposes player goon,soonlyinthiswaycanthepurposebefulfilled. or amusement’. in fordiversion because eveninaseriousgamecanbedefinedasan‘activityengaged Amusement makesthe these ‘serious’to achieve role an important still plays games. Entertainment is unimportantforserious that entertainment mean purposes, other thanentertainment has aprimarypurpose as agamewhich In itscurrentcontext,aSeriousGamecanbedescribed which wasafirst-personshooterintendedtofamiliariseplayerswiththeUS Army andserveasarecruitmenttool. It has been suggested[1] that the term after gained prominence the American militaryreleased thevideogame America’s Army ‘Serious Games’ arenotaspecificgamegenre,andanytypeofcanbeutilisedinthatcontext. for funorrecreation. that isnotexplicitly with anobjective inconjunction principles design the game-based to anyactivityappthatutilises Game’term ‘Serious such aswargames from militaryapplications formsanduses,ranging hasbeenaroundformanyyears in various Today,for manydifferentGames aredeveloped Serious of theterm.Mainly,conclusions misleading and therearecommon purposes, the The term‘SeriousGames’ adolescents andwasdevelopedbyPromotionSoftwareGmbH(Germany),acompanyspecialisinginthedevelopmentofseriousgames. (UK). of Bedfordshire by theUniversity motivated goals.Onefocusesonadultsandwasdeveloped and The othergameisforchildren to setself- encouragement and evaluation on psycho-emotional an emphasis with element anessential became games Also, twoserious patient groupsandfocusingonthewell-beingofcancerpatient. a personalhealthrecord(PHR)(iphr.care) platform including cancer diseaseself-management according to the specificneedsof designed long-term surveillance. in manycasesasachronicillnessrequiring and providesa project reflectsthisdevelopment The iManageCancer The treatment and personal situationof cancer patientshavedramaticallychangedoverrecentdecades. The disease cannowbemanaged Introduction 2 www.ecancer.org ecancer [3]. This doesnot 2018,12:850 [2] in 2002

Short Communication when possible’ mode. fine socialgameelementsdescribedlaterinthisarticle. to beplayedoffline,This gamewasalsodeveloped withsome kindof‘goingonly platform. by theiManageCancer the devices,controlled between communication The seriousgameforkidsallows This isusedforsome patient’s datafromtheplatform. platform iphr.care.an offlinefor adults,thereisalso game Fortheserious the of retrieving the advantage not have does which version, to Both gamesweredesignedestablishaconnectionto the internetandexchangedatawithagamebackendiManageCancer iterated inPhotoshopandthenmodelled,rigged(=preparedforanimation)animated3DSMaxZBrush. and designed and more.3-Dmodelslikethe cancercellswereoriginally processes of improved editing the gamelevels,enemybehaviour for was enhanced for kids,theeditor game of Unity3-D.Fortheserious editor with theinternal animated in C#and The gameswereedited a highchancethattheresultinggamesarefuture-proof. to thetargetplatform exported to supportfutureplatforms,sothere’sa varietyoftargetplatformsandisplanning Unity 3-Dallows Android. development of 2-D and3-Dgames. The development workscross-platform. The software can be tested instantly onthe PC and after this Android. was chosen. base, theUnity3-Dengine As atechnical the framework whichallows 64-bit gamedeveloping This isaverypowerful As a resultof for this mobile gamingplatformsliketabletsandsmartphones,for analysis, bothgamesweredeveloped the operating system That showsquiteclearlythataPCorPS4consolewith TV isnottheproperdeviceforourprojects. productive effects [25]. As aresult,wereducednarrationtominimum,butdidnotresignitcompletely. points outthatusingnarrativeelementsinaSeriousGamehas counter- Some researchresultsseemtobetransferable,someta-analysis learner variables,proceduralvariables(i.e.game-basedpedagogy) andgamevariables(e.g.genremedia). setting), (i.e. learning variables administrative and methodology), (i.e. researchpurpose tional gamingisfragmentedbyresearchvariables Ke than conventionalinstructionmethods the Design Elementschosenfor the game [24], regarding but actualmeta-analysisconfirmsthat serious gamesoverallaremoreeffective between differenton ‘Re-Mission’), genres, it is nearlyimpossible[4]. It is assumedthat the effectiveness of Serious Games is mixed, the many facets which seriousgamescanhave.Evenbetweensimilarwithinonegenrecomparisonis difficult (see references of theeffectResearch with to comebasicconclusions impossible that itisnearly facing theproblem gamesisstillongoing, ofserious Serious gameeffects game. Inourcase,thehardwarehastomatchfollowingcriteria: Choosing a hardware platformfor a game is always a decision that has to consider manyaspectsof the typical usecase we foreseefor a Technical aspectsofdevelopment references andseveralseriousgameeffects describedintheresearchliterature. of a review aspects and are theusecases,technical here aspects tomention the games,mostimportant behind the basicidea had tobedonemakethebasicdecisionsforgamedesign. Beyond the gameprototypes,essentialgroundwork Before developing Essential groundworkforthedevelopmentprocess o o o o [5] pointed out that, consistent withthe finding of previous gamingreviews,this analysis indicatesthat the empirical researchon instruc- The deviceallowsindividualaccountsand—permanentortemporary—accesstotheInternet. The deviceishighlyattractiveforchildrenandadults The devicecanbemadeavailableeasilyforchildren The devicecanbeusedinhospitals [25]. 3 www.ecancer.org ecancer 2018,12:850

Short Communication Figure 1.Screenshotofthegame‘Re-Mission’ showsanin-game situation. nents forbetterpatientsupport. mechanisms. motivational compo- also thegamehasacoopmodeandstrongsocial for younger children, are moresuitable The graphics is. Moreover,medicine important daily works, andhow that medicine part toagamewithstronger thefocusshiftedfromeducational shows theway ‘Re-Mission’—and to fightagainstcancer—like platform motivateschildren The seriousgameforkidsintheiManageCancer in adolescentsandyoungadultswhowereundergoingcancertherapy The interventionwith‘Re-Mission’self-efficacyof cancer-related and indicators treatment adherence improved significantly andknowledge with a4.6-million-dollarbudget. kinds ofcancer.and psychologists animators, cancerexperts,biologists by manygamedevelopers, game developed Itisapath-breaking medicine. the importanceofingesting recognising and the disease against by fighting herself 20 stageswithdifferentincludes The game body duringdifferent cancerdiseases. The ideabehindthegameis: by killingthecancercellswithhero,usermotivateshimselfor ‘Re-Mission’1 ) (Figure ‘Re-Mission’ adults. Two gameswithasignificantinfluencearedescribedhere. which arerelevantreferencesfor Several seriousgamesareavailable the design of the serious gamefor kids andthe serious gamefor Other relevantseriousgames positive attitudeabouttheircancertreatment. [6]. me andcharacters withanextremely transfers, anidealised usessimilar games foriManageCancer method intheserious The adaption from others,e.g.with‘models’learning than theplayer, (charactersandavatars)thatareolder of correctbehaviour tofacilitatetheadoption game forkids,anothereffectFor theserious wasimportant. Agames istopostulatethe in video learning social commonwaytorealise is a serious game for children with cancer and for their relatives. for their and with cancer for children game [7–9] isaserious a human in happens what explains The game 4 www.ecancer.org [23]. ecancer 2018,12:850

Short Communication Figure 2.Screenshotofthegame‘Crusaderslostidols’ showsanin-gamesituation. The targetsofthedesignseriousgameforadultswere: ously ongoingbalancingprocesses. person’s cancer disease they can stillbehappyand achievea sense of It wellbeing. also transmits the idea that all choicesrelyoncontinu his/her cancerfromadifferentrounding perspective. The gameisintendedto ofa promote theconceptthat with agoodmanagement problems. the issuessur- viewing also time, while and resources in ordertobalance and strategically to thinkcritically The userisinvited role of a mayor, an authority figure (see [8]), who managesa lifestyle small townwherehe/shehelpsresidentswiththeircancer-related Toprocess, weputhim/herinthe givethefeelingtoplayerthathe/sheplaysarelevantroleinthisgameandalsorecuperation showed thatseriousgameplayersbenefitmorethanthecontrolgroup a healthierlifestyleand better disease management. As pointed out in [11], two of six studiesaboutself-managementof the disease able to manage andto face their disease,alsoto support the patients dimension of in dealingwiththe their disease,promote psychological The idea of the game is to encourage the player to proceed inthis process andpromoteself-efficacy, i.e. the belief of the patients to be critical thinkingandstrategy. The playersareinthesituationofreorganisingtheirlivesandmayhavetorethinkhabitslifestyle. The serious gamefor adults aims to help users engage with the wider iManageCancer platform while placing them in a situation requiring Objectives andgamedesignbasicsoftheseriousforadultswithcancer gamewithavatarsandstatsoffriendssupporterstobeusedinastrategicmanner.to populatetheseriousgameforadultplayer’s and strategicallypositioningalliescanbecombinedwithadesignthatdoesnotinvolvereal-timemultiplayertactics,providinganopportunity adventure game. The gamecanalsobeleftunattended,leavingthecharactertoautomaticallyexecuteitsstrategy. The mechanicofrecruiting ‘Crusaders of the Lost Idols’ (Figure 2) is a web-based game available from Kongregate ‘Crusaders oftheLostIdols’ (Concrete) • (Meta)Improveself-efficacy inself-managementskillsthroughmasteryandvicariousexperienceofthe • (Meta) • (adjustment-oriented self-managementapproach) To createagamethateducatespatients(andindividuals)toengageinhealthybehaviourswhilehavingfun Convey healthier

lifestyles (balanced diet and 5 www.ecancer.org appropriate [12]. physical [10]. This game is a side-scrolling click and drag exercise) and improve Avatar intheseriousgame. ecancer problem-solving 2018,12:850 skills -

Short Communication the buildingsfromacompletely different perspective. the streets. through 3-D graphics. in realtime This partofthegameisshown at alltimestoshow of thecameracanbechanged The position and streets. Figure 5showsthemainviewofgamewhichcitywith allthebuildings Also, theplayercharacteriswandering Put theuserinacriticalsituationforstrategy ofsolutions activities withinthetownorbuildacertainbuilding. are given. and newchallenges in thegame,newlevelsbecomeunlocked Once theplayerproceeds a numberof This canbetocomplete is togetthiscitizen’s wellbeingvalueto100%. aim must assist(Figure4). presented byacharacterthatplayers aim toachieve, an individual Each gamelevelgivestheplayer The user’s Give theuserprogressiveaimsandmissions Once thecharacterisindividualisedplayerconfirmsandmayorstartsingameworld. The gameallowsalotofmodificationstheavatarwithincharactergeneratorincludinghairstyle,eyes,mouth,glasses, genderandclothing. cess tocreateanindividualavatar( We wanted to give the player the possibility to find instantlyanavatarfor identification inthe game. Therefore, the game starts with a pro- Creating anavatar corrections ofideasthatwerenotworking. This learningisdescribedinthesection‘Evolvingdesignprocessgamedevelopmentphase’. formed. The followingsectiondescribes thegameplayofgamestep-by-step. The developmentprocesscontainedalotofiterationsand From thefirstbasicideaofamayortownwhoprovideslotpublicandpersonaldecisionstoplayer, afirstgamedesigndraftwas The seriousgameforadultsstep-by-step challenge. The mini-gameisrepeatableanddesignedtodissuadethefictionalcancerpatientfromunhelpfullifestylechoices. leverages alargeset element throughamini-gamewhich also providesan of educational health andlifestyletriviaquestionsinaquiz-style character.a fictional context using a controlled within lifestyle management of good examples to provide opting instead changes, The game lifestyle appropriate the userabout advise or specifically recommendations of thegameisnottomakemedical method The teaching Figure 3.Screenshotshowsthecharactercustomisationmenufromseriousgameforadults. Figure 3). This characterfinallyrepresentsthemayor inthegameworld. 6 www.ecancer.org ecancer 2018,12:850

Short Communication motivate theusertoengagein morephysicalactivity. prize inthegame. beneficial platform andpotentially ausertoutilisemoreoftheiManageCancer to encourage The featureisintended Currently, for the featureallowsuserto a spinonprizewheelthat buy arandomprizechancebox,thisboxisexchanged yields asmall to spenditwithinthegameasaformofcurrency. utilises theirphysicalactivity data, this applications andallowsthe data is user to collected throughotheriManageCancer convert it in order users canaccessafeaturethat iManageCancer software.Registered as stand-alone mainly The seriousgameforadultsisnotdesigned The integrationoftheseriousgameforadults intothe‘iManageCancer’ platform designed tostimulatecriticalthinkingabouttimeandlifestyle. the goalsandactivitieswhilenotalwaysbeingmedically relevantto choices cannowleadto ‘Poor’ the userare negative well-being, rent resourcesofthetowntoproceedonanoptimalcourse100%wellbeing. the citizen’s ofbalancing The playerisfacedwiththechallenge timeandbudget,theymustconsidertheneedsoftheircitizencur- city orusingthecity’s infrastructure(likebuyinghealthyfoodorjunkfood). of thecity.From here,thestatuscanbeseen,alsodevelopment or anestateoffers Selecting abuilding theopportunitytodevelop Figure 5.Screenshotshowsatypicalin-gamesituationintheseriousgameforadults. Figure 4.Screenshotshowsadoctor’s ordertotheplayerinseriousgameforadults. 7 www.ecancer.org ecancer 2018,12:850

Short Communication symptoms, above distress andtheinchildren,e.g. children of and externalising depressed mothersdisplayavarietyof internalising the child’sinfluences of effects responsesandfunctioning,inacircularsequence reactions. Muchmoresupportincludesthe whole family.than withadults,the chological psychological How a family respondsto adversity is stony,but thepathtoacure is verygood, treatments forchildren of cancer The outcome effectsside physical numerous with psy- and better effect thanwithpassivemediaconsumptionlikewatchingcartoons. cells. the cancer against games, with a with video and anxiety pain for reducing recognised is already distraction The methodofchildhood cians andparents,becauseof the side effects of the treatment, and thegame shouldhelpto lead theseaggressions inthe right direction, Another objectiveof the designwasto lower thechild’s resistance againstthe treatment. against physi- There alsomightbeaggressions applied (whichisspecificallyafiguraltransfer, asdefinedbyRoyer exist andthatpatientscancombatcancerifproperly that weapons children: for younger and understandable isquitesimple of learning cancer cellswithdifferentbody andfightvirtual cancer.tools against clinical that representthetherapeutic weapons transfer The intended role inthetreatment. cancer butalsoplayapassive in fightingagainst involved The playerstravelinavirtualvesselthroughhuman design isto show children that and relativesshouldbenotonly fighting againstcancerisanactiveprocessfor the child.Childrenactively referred toasthetransfersource)affectthe inanewsituation(thetransfertarget)[14].So,theideabehind and performance learning in reality.to thesituation Transferthe effectiveand as theprocess described is usually oflearning (also past experiences extenttowhich One ofthebasicobjectivesseriousgameforkidsisimprovementself-efficacy,in thegame based onatransferoflearning Objectives andgamedesignbasicsoftheseriousforchildrenadolescents withcancer The next step in the development will be to prove if all the enhancements lead to a measurable improvement regarding the mentioned issues. features likedifferent clothesorhaircolourswereaddedtothegame. who tendto the socialiser roleinthe scheme of the Bartle Test type ofplayer,for acertain significance of theavatarhasahigh that the individualisation an insight There wasalso for players especially and tutorialswereintegratedintothegame. of thegame. of theplayerandrequirements became visiblebetweentheknowledge Topossible, hints makethetransferoflearning Other learnings fromthisfeedback werethat the targetgroupand the usecasebecamemuchmorecarvedout. In fact, an informationgap challenges werecontrarytotheirreal-lifesituationsresultingfromcancer. These changesalsoaddressedtheissueof users tryingto in thegame—inmanysituationsthese relate toocloselyto the challenges their roleandthenatureofactionsgameexpectsthemtoundertake. regarding the roleofusertothatasupporterfictionalcancerpatientconfusionmanyuserswasaddressed By changing oncology educationprovider. This hasledtoseveraldesignchangesnotonlyoftheinterfacebutalsocoremechanics. by held from workshops was collected Early feedback TenovusCare, aWelshCancer charity,cancer by ecancer,initiated and aleading Evolving designprocessinthegamedevelopmentphase current appearanceandcontacte-mail. town providinga passive effect.friend to occupy the user’s The social profilescontainnomedicaldataor information beyondtheiravatar’s play,form ofsocial asynchronous is an mechanic social afriend’sthe that allows there isamechanic and in thegame viewed can be profile a usercanalsosearchforotherpeople’sand migration Further tobasicgameprofileuploading and sendthemfriendrequests. profiles This platform. the iManageCancer to theirPHRwithin service the backend through is forwarded data which audit and feedback users toprovide Registered userscanalsosavetheirgamedatato a gamebackendserviceoncetheyhaveloggedin. This serviceallowsfor registered [13]. To supporttheseplayerswithsocialiseremphasis,morecustomisation [20]). 8 www.ecancer.org [15, 16]. [17]. A positiverelationhasbeenfound betweenparental ecancer 2018,12:850

Short Communication Figure 6.PictureshowsseveralversionsofthecancercellOverview (2-Dversions)fromtheseriousgameforchildrenandadolescents. that affectshow use caseofourgame,and the veryspecial a lotabout welearned development, but during the beginning, thegamedesign. Like the serious gamefor adults, the serious gamefor kids wasdesignedinan iterative process(Figure6). Many basicideaswere set in The seriousgameforkidsstepby project. founded feedbackisexpectedwiththepilotsof‘iManageCancer’ More which pointedoutclearlythatthesecancercellsdon’tscarethechildren. des Saarlandes cancer patientsattheUniversitätsklinikum mean, butstupid. Youguys, sostartfighting!’. these dim-witted against haveachance to young drafts wereshown and advanced The early look should was set:‘Theenemies art stylepremise pals. So,thefollowing them asfriendly to show be wrong it would on theotherhand, this way.in addressed also was cells, One verycriticalaspect,thelookofcancer but, children, younger not scare should The cells making itsuitablebothforyoungerchildrenandadolescents. Something similarcouldbesaidabouttheart style. We orientedonmodern animatedmovies,whichusuallychooseanallageart style, the childrenwon’ttouchaboringgame. worth when real of no of theseare all achieved, are goals many paedagocial of how Regardless fun forthechildren. really the game make to others was all over premise so thefirstdesign game, of every the firstaim be should entertainment in theintroduction, As mentioned cell. Everyplayerthatfightsthiscancercellsuccessfullycollectsastickerinhis/heralbum. cancer (if theytookpartornot)canfightaverynastyspecial players and all opens for thecurrentweek,arena summed upfulfilthegoal the game. week byweek.Ifallthegameresultsofplayers is measured mode worksasfollows:playsuccessofallplayers This arena to initiatesocialinteractionbetweenthepatientsand tothealreadymentionedsocialfeatures,arenamodewasdesigned In addition cancer cellsbecomeinthegameofchild. game’s forthechildren’s achievements playsuccess. against the weapons for thechild,morepowerful play The morethesupporters have limitedcontactwithfamilyandfriends. supporters (familymembersandfriends)toplaycontributethe The seriousgameallows treatment’them alsoanimportantpartofthe‘in-game inthegame. of thekids inthehospital,whenthey the isolation This alsoaddresses and make the familymemberstosupportillchildren features, allowing with social As aresult,theseriousgameforkidswasdesigned would havealackofeffect withoutincludingfamilymembers. of the anxiety children [19]. of achildwithcancer ofempowermentandresilience that anenhancement This leadsdirectlytotheinsight the anxietyofparentsand found between mothers [18].Otherlinkshavebeen of non-depressed by children and beyondthosedisplayed 9 www.ecancer.org ecancer 2018,12:850

Short Communication 10 www.ecancer.org Figure 8.Screenshotshowsthemainlevelselectionscreenfrom theseriousgameforkids. Figure 7.Screenshotshowstheinitialdecisiondialogforgamemodeinseriouskids. a unisexdesign,becauseplayerscanbemaleorfemale. An image showingthe silhouette of a human bodywithseveralinnerorgansis used asthe level selectionmap(Figure8). The figure has Selecting alevel shown aspotentialwinnershere. The wholescreenshouldworkasaninvitationtostartthegame. for thebattle. confidence the player give attitude and a verypositive to show is designed screen The selection are the patients This iswhy can’t beprohibited. The intentionwasalsotomakeclearthateveryonecouldbeasupporter. in shown The screen When theseriousgameforkidsisstarted,playerhastomakeamajordecisionfirst. Choosing agamemode is designed to make it clear that the explorer/patient mode is reserved for children with cancer.with for children is reserved mode that theexplorer/patient it clear to make 7 isdesigned Figure Infact,misuse ecancer 2018,12:850

Short Communication 11 which addalotoffirepowertotheirplay. When thepatientplayersopenoneofgiftboxesdistributed byasupporterplayer, they findshieldsandveryeffective extraweapons, more extensiveintroductiontothegamethanfriends. ‘patients’. friends’and into afamily is split mode The ‘supporter’ a may need members that family the problem addresses which submode, to support. a person Travellingmakes the‘supporters’cancer cells and fighting the levels through presents totransfertheir findspecial a ‘supporter’. can become everyone mode ismadeforfamilyandfriends,buttechnically The supporter Ahas tochoose always ‘supporter’ The supportermode challenge becauseoftherisingdegreesdifficulty. the finger. automatically.and shoots permanently The vessel offeringbut still children, for younger simple That makesthegame enough to be asintuitivepossible. The gamecontrolsaredesigned The playercontrolsthevesselbysimplytouchingscreenandmoving In themiddleofscreenisagiftbox. They onlyappearinsupportermodeandcanbecollectedforthepatients. simple andreducedtoshootingthem. meets differentand body of thehuman the capillary travels through The vessel cells. cancer is quite cells with thecancer The interaction After selectinggamemodeandalevel,thestarts. Fighting thecancercells some shipimprovementmenusandahelpscreencanbefoundthere. choosetheleveltheywanttoplayorswitchthroughseveral menuswhicharelistedinthetopline. From here,players A highscorelist, Vessels, Stomach,SweatGlands,HeartandBrain. are visualised. locations game/level Only theorgansofaccording The levelstakeplace atfivepointsofthehumanbody:Capillary Figure 9.Screenshotshowsatypicalin-gamesituationfromtheseriousgameforchildren(supportermode). Figure 9showsatypicalgamesituationforsupporter. www.ecancer.org ecancer 2018,12:850

Short Communication 12 www.ecancer.org like grandparents seemto than friends orsiblings. problems have more comprehension Younger persons,alldigitalnatives,mayhave organisation, Tenovus,relatives (here the game behind the meaning and mechanics the game do notunderstand that testplayers showed to thegamesomekind ofpaperhand-out. idea foraseriousgamekidswastointroduce The original The feedbackfromthetesting of difficulty wereaddedtothegame. The moreadvancedtheplayersare, thefastercancercellattacks. by theirdisease. but therearealsoplayerswhohandicapped and adolescents only youngchildren As a result, threedifferent degrees sufficientlyAnother aspectthatwasnotconsidered wasthedifferences in the beginning intheskillsofplayers. The targetgroupisnot is alsohighlywelcome—whichresultedinseveraluserinterface changesthatmakeiteasiertoswitchbetweenpatients. sufferer,for thefellow play will the children use case.Inhospitals, the typical enough this support bed, and in theneighbouring thepatients In theearlystageofdesign,therewasastrongemphasisonrelationbetweenfamilyandyoungpatients. This didnot dignify porters, cancontributetothecommongoalopenarena. on theiphr.careplayers from thedoctorstoall be thateveryplayer,might aspect ofall platform.Butthemostimportant withorwithoutsup - Withoutanysupporters,playersfindpresentsontheirown. have nosupporters. to distributepresents were implemented Also, mechanisms they because the game, in weak not feel do sure thatplayers can make but thegame problem, the underlying solve itself cannot The game game becomeseasierthroughthehelpofothers,thenitisobviouslymoredifficult (andprobablyveryfrustrating)whennosupportisgiven. Another learningoutcomeisthatsocialaspectsmightturnintosomethingnegativewhensupportnotgivenbyother people.Whena and friendsbecomeavailableonthemobiledevicesofkids. data exchange. visit, theycanestablishahotspotforwhiletoallow After thistransfer, gameresultsandall thepresentsofgrandparents Athe parentscomefora and when without anInternetconnection, plays withadevice in hospital typicalusecasemightbethatthechild shooter andmatchthree. start of the game that they are offline andgameresultsarestacked. The game itself remains fullyplayable,patientandsupporter mode, process. Whenthere’sthe login have tohandle doesn’t usually So, achild at the get amessage to theInternet,players noconnection An offlinein successfully,logged modewasintegrated.Onceanaccount isinitially not askforloginagain. thegameremembersthisandwill be addressed. about thegamewasthat thisneedsto learned the game.So,oneoffirstlessons playing access totheinternetwhile have permanent don’t probably use casewas thattheplayers the final elements, butoneresultofreconsidering was thesocial of thegame One mainidea Evolving designprocessinthegamedevelopmentphase exchange isstoredmeanwhileuntiltheconnectionbackagain.) via iphr.care, thedatatransferismandatory(Theexceptionthat without connectionto the Internet, the gamecanstillbeplayedanddata can beseenand for are availableresearch. Also, an audittrailabout the game processis stored onthe platform. As all socialfeatures work PHR platformiphr.care.The seriousgameforkidsalsoreportsresultstotheiManageCancer Here,activityandsuccessinthegame playtime. Parentalcontrolmechanismsareimplementedtoreduceparentalconcernsabouttheuseofseriousgames. supporters orreducing the accesstogameviaplatform,suchasdisabling controlling that allow in place There aremechanisms usually youngkidsdonotseethis)andallgameresultsaresenttoaserverthatrealisesthesocialfeatures. in, so is logged the device once the background in happens (which a login have for kids games that theserious it mandatory This makes game—and viceversa. platform. The seriousgameforkidsisfullyintegratedintothe‘iManageCancer’ Accounts fortheplatformworkasaccounts How theseriousgameforkidsisintegratedinto‘iManageCancer’ ecancer 2018,12:850

Short Communication References tion itcontains. No 643529. reflects theauthors’This presentation view. of theinforma- for anyusethatmaybemade is notresponsible The Commission Union’s fromtheEuropean funding This projecthasreceived grant agreement under programme innovation and research 2020 Horizon Acknowledgments the efficacy oftheseriousgames, theywillalsobeusedforanotherenhancementcycle. patients involved. 100 after thepilot. be held will workshop An evaluation into insights to new lead not only from thiswill The conclusions above. as described was addressed project,withmorethan became readyforthepilotphasein‘iManageCancer’ The gamesfinally In the Tenovus testingsessions,bothgamesshoweddeficitsinthecaseoftransfersasmajorissue,andcases,this learning in particularimprovedtheunderstandabilityofgamebyaddingatutorialmodeanduserinterfaceelements. help themtofocuson‘therealenemy’ andprovidesomepowerfulsocialmechanics. The gamewentthroughseveraldesign changesthat cancer,a positiveattitudeintothefightagainst to bring was designed and adolescents The gameforchildren makethepatient’s roleactive, challenges fromtheirwellbeingmeteringame. of clearing mechanics by theexplicit reinforced a principle a senseofwellbeing, achieve and caused bycancer life in their the challenges overcome can helpanindividual in healthylifestylemanagement The primaryconceptofthedesignistoreinforceideathatengaging incentivise thedevelopmentofcriticalproblem-solvingskillsthroughmasterygamemechanicsandin-gameitemrewards. experiences. and vicarious through exploration Tousers for ineffective thisend,thegamehasavoidedpenalising play, instead it aims to throughout. to learn the needforpositivefeedbackandopportunities have considered madefromthebeginning decisions The design for adultsoffersgame The serious action atitscore positive and keeps lifestyle which mechanics play game engaging and colourful Conclusion ment regardingthementionedissues. As in the serious gamefor adults, the next step in the development willbeto prove if all the enhancements leadto a measurable improve- game stepby step. In a second iteration,weaddedalittletutorial character andsomemoreextensivetexts that add alittlebitof narration. a much easierandmoreintuitive approach to video games).So, a short tutorial withvery short instructions wasaddedthat explains the 4. 3. 2. 1. 6. 5. Giessen HW(2014) 495-0.ch006 on ImprovingLearningandMotivationthroughEducational Games: Multidisciplinary Approaches Djaouti, Julian Damien Jessel (2011)Alvarez, andJean-Pierre Classifyingseriousgames:theG/P/S model [http://www.americasarmy.com/] Dateaccessed:17/01/2018 Susi T, JohannessonM,andBacklundP (2007)Seriousgames—anoverviewPsychology Manning (SantaBarbara:Lawrence Erlbaum Associates) pp103–120 health Lieberman DA (1997) Interactivevideo games for health promotion: effects on knowledge, self-efficacy, social support, and tronic gamingineducation Fengfe Ke(2009)A Qualitative Meta-Analysis ofComputerGamesasLearning Tools Health Promotion and InteractiveTechnology:Health Promotion Theoretical and Future Directions Applications Serious gameseffects:anoverview 1 1–32 Procedia 13 —Soc BehavSci1742240–2244 3(12A) Handbook of research oneffectiveelec- Handbook

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