I Don’t like Gaming, It Leads to a Pressure to Perform: Older Adults

Refused Gaming Elements in a Digital Home-based Physical Training

Programme in Two Qualitative Studies

Claudia Oppenauer-Meerskraut

, Johannes Kropf

, Anna Bösendorfer

, Matthias Gira

Mario Heller

, Kerstin Lampel

Andreas Kumpf

and Tanja Stamm

1,*

Institute for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems,

Medical University Vienna, Spitalgasse 23, Vienna, Austria

Center for Health and Bioresources, AIT Austrian Institute of Technology, Donau-City-Straße 1, Vienna, Austria

University of Applied Sciences FH Campus Vienna, Favoritenstraße 226, Vienna, Austria

St. Pölten University of Applied Sciences, Matthias Corvinus-Straße 15, St. Pölten, Austria

WPU GmbH, Föhrenweg 14, Baden, Austria

Keywords: Physical Activity, Older Adults, Kinect, Avatar, User Requirements, User Experience, Qualitative Methods.

Abstract: Background: Physical activity in older adults is an important protective factor for preventing morbidity and

mortality and increases well-being and independent living. Within the so-called “Train and Win” project, a

physical home training program with gamification elements based on the Microsoft Kinect sensor and an

avatar will be developed. Method: Two user studies using a qualitative approach were conducted in order to

guarantee a user-centered design: a focus group with 14 participants and a mock-up study with seven

participants. Results: Contrary to published literature and our expectations, a majority of participants (8/14;

57%) explicitly refused gamification elements, such as competitions between the participants or

motivational design inputs for process feedback. Thus, the training program should be related to the

physical training experiences of the participants which were mainly sports and be “realistic” in terms of the

presentation and interaction with the avatar. Both studies showed the necessity for an individually designed

training, including typical non-technology aspects of a physical training. Conclusion: The results stress the

importance of considering diverse attitudes, technology experiences and needs of older adults. For a high

user acceptance, the training has to be individually adapted and consider more traditional non-technology

training elements than gamification issues.

1 INTRODUCTION

Physical activity is a major factor for enhancing

older adults’ health, functioning in daily life,

independence and cognition. (WHO, 2011). Older

adults who are regularly physically active have a

reduced risk of falling and live longer

independently at home (Bherer et al., 2013).

Nevertheless, aging related declines of physical

health, cognitive functionality and social

engagement can reduce the engagement in physical

and daily activities (Reuter, 2012).

Numerous programs to facilitate physical

activity in older age exist. However, they need to be

personalized and well-fitted to the needs of

individuals who use these programs. Digital

technologies offer innovative possibilities to deliver

well-fitted exercises at home, to ensure regular

training through motivation and to give feedback

tailored to the individual needs (van Diest et al.,

2013). A user-centered design approach ensures that

the expectations and needs of future users are met

already during the development of a new

technological product to ensure optimal acceptance

and applicability.

In this work, the user-centered design approach

for the creation of a virtual training system using

gamification elements is presented. Sardi et al.,

(2017) discuss the relevance of gamification in e-

Oppenauer-Meerskraut C., Kropf J., BÃ˝usendorfer A., Gira M., Heller M., Lampel K., Kumpf A. and Stamm T.

I Donâ

Zt like Gaming, It Leads to a Pressure to Perform: Older Adults Refused Gaming Elements in a Digital Home-based Physical Training Programme in Two Qualitative Studies.

DOI: 10.5220/0006516901780184

In Proceedings of the International Conference on Computer-Human Interaction Research and Applications (CHIRA 2017), pages 178-184

ISBN: 978-989-758-267-7

health and summarize the most significant

gamification elements which are a mix of game

mechanisms (e.g. points, badges, leader boards,

rewards) and game experience design elements (e.g.

countdown, storyline, discovery, quests and

challenges, levels) in non-game contexts

(McKeown, 2015). A mean of promoting

competitions is making tasks and outcomes visible

to other users (Park and Bae, 2014). All these

gamification strategies aim to increase long-term

engagement/motivation and make (physical)

activities more pleasant for the users.

In the present project, an occupational and

physical therapy-based training module for

prevention and facilitation of mobility and

flexibility for people at the age of 65 and older is

developed based on two qualitative user studies. An

Information-Communication-Technology (ICT)

based system with a Microsoft Kinect sensor is

installed at the user’s home using their own TV set,

showing a motivating avatar who gives feedback

and tips on general health awareness and health

literacy. In order to explore user requirements and

needs for the training program, two user studies

were conducted using a qualitative approach prior

to the development of the system.

Various studies have shown a correlation

between beginning age related limitations of

physical activity and mobility with multimorbidity.

An akinetic lifestyle has a negative impact on the

cardiovascular system (Wei, 1992), the

musculoskeletal system (Plaumann and Walter,

2008) and the respiration system (Heinhold and

Plesch, 2004). Tschannen and Gertsch

(2007)

investigated the positive influence of active

mobility of older adults on self-esteem, identity and

independence, and further implications for social

inclusion and integration. Additionally, activity

reduces the risk for age related depression

(Gallaway et al., 2017).

A positive effect of exergames could be shown

in the past by van Diest et al., (2013). Larsen at al.

(2013) have performed a meta-study and could

derive a positive effect on balance, agility and

motivation by increased mobility in old age from 7

out of 8 considered studies. Nevertheless these

studies have also shown that systems currently

available on the market are not sufficient to ensure

large and sustainable effects on health.

2 USER CENTRED DESIGN

APPROACH

To determine user requirements regarding the

physical training program, a qualitative approach

was used: (i) a focus group with 14 participants

discussing major needs and requirements for the

training and (ii) a mock-up study with seven

participants investigating design and understanding

of interface design ideas.

Participants of both studies were healthy older

adults from the age of 60 living independently at

home and interested in the participation of the

physical training program. Thus, results of our

studies presented here can only be interpreted with

regard to a motivated group of people willing to

increase physical activity levels. For an adequate

training participation, “healthy” was defined by the

following exclusion criteria: (i) Participants should

not take regularly medication which influences

balance or coordination in a way that it prevents

them from participating in the present study; (ii)

participants should have no other un-treated

psycho-neuro-motoric diseases; (iii) participants

should not have visual or hearing impairments

which could interfere with performing the training

program; (iv) participants should not have any

chronic diseases which are incompatible with

performing the training program and (v)

participants should not have any self-reported

problems with balance.

All participants were from the same rural region

in Austria and recruiting was supported by the

regional project partner “Mühlviertler Alm”.

3 FOCUS GROUP STUDY

The focus group study was the first qualitative sub-

study in the project investigating major user needs

and requirements for the physical training program.

A semi-structured interview guide dealing with the

topics leisure activities, sports, use of technologies,

use of technologies in the area of leisure and

mobility, expectations and needs for the training

program, expected benefit and reasons participation

in the project was used. An example question was:

“Please describe your experiences with home

training videos or home exercises.”

All participants were informed in detail about

the procedures of the study. They were asked to

sign an informed consent before the start of the

group discussion. The study was submitted to the

Ethical committee in Upper Austria.

3.1 Methodology Focus Group

In a first step, audio material from the focus group

was transcribed and amended with the notes of the

focus group moderator (CO) who was an expert for

user centred studies. Secondly, the transcribed

material was analysed with the comparative content

analysis method (Coenen et al., 2012). In this

method, data is organised in categories respecting

also frequency aspects of the qualitative data.

Categories were further splitted in main issues and

meaning units. A disadvantage of the focus group

methodology is that not all participants equally

responded to the same questions. Thus, results were

not representative for the whole discussion group

(Goodwin and Happell, 2009).

3.2 Focus Group Results

Overall, 14 (4 female, 10 male) older adults

participated. All but one participant were already

retired and mean age was 67.2 years (SD = +/-3.9).

3.2.1 Leisure Activities/Sports

In general, the focus group participants were active

in terms of leisure and sports activities. More than

half of the participants go cycling (8; 57%) and

hiking (7; 50%). Five participants (36%) go

routinely for a walk and four participants (29%)

conduct regular physical trainings with specific

YouTube videos at home. Further activities (each

activity was named by one person; 7%) were

swimming, dancing, skiing, tennis, cross trainer and

martial arts.

3.2.2 Motivation for Physical Activity

The participants’ reasons for physical activity were

quite broad and go beyond the straight definition of

physical activity. One male person said “You feel

better afterwards. Everything is much easier.”

Motivational reasons for being physically active

were self-perceived/self-reported increased well-

being (3; 21%), physical fitness (2; 14%),

improvement of sleep quality (1; 7%), maintenance

of body weight (1; 7%), need for movement (1;

7%), psycho-hygiene (1; 7%), knowledge about

positive effects of physical activity (1; 7%),

corporate feeling (1; 7%).

3.2.3 Technology Experiences

Some participants used technology for supporting

their physical activities. Only two persons (14%)

used a smartphone application with reminders and

monitoring of running/walking, one person (7%)

uses a step counter app and another person uses a

step counting wristband. Two persons use YouTube

videos for physical training at home, one person has

once used a game console together with

grandchildren for a physical activity game.

3.2.4 Expectations Training

Eight participants (57%) explicitly refused

gamification elements: five persons (36%) wish to

see their personal training score/training

development only. Three persons (21%) explicitly

emphasize that they do not want comparisons in or

between the training group and all other participants

of the focus group agreed. One male participant

said:

“I don’t like such networking processes within the

group because then a pressure to perform arises.”

One person stated that it would be ok if this

comparison would be anonymized. Further, a need

for assessment of pain during the training was

pointed out (2; 14%).

Regarding the expected benefit of the training

program, five older adults (36%) reported a holistic

health awareness meaning the program should

recommend health related issues for a healthy life

style as well. One female person said:

“For me, it (the program) raises awareness that

physical activity is something important for us and

that we all can do something on our own to remain

our personal health and stabilize a given

condition.”

Respectively once other statements were: fall

prevention, increase of mobility, increase of

balance, increase of coordination and physical

resilience, corporate team feeling and motivation to

move.

For the training program two persons wish for

an individually adaptable training. Other

requirements for the training vary from person to

person: various exercises, feedback for

improvement, exercises should be chosen by

experts for physical training/physiotherapists,

exercises with bottom-up difficulty levels,

recommendations for exercises without program.

Concerning the interface design the

requirements differ between the participants. Ideas

for the appearance of the avatar or the design of the

main menu vary significantly between the

participants. There are also some participants who

would like to exercise with music.

4 MOCK-UP STUDY

In a second step, a mock up study was done in order

to evaluate attitudes and user experience of first

designs of the interface and elements of the training

program. Further, the mock-up study should reveal

deeper insights into motivational gaming aspects of

the training program presenting specific designs.

4.1 Methodology Mock up Study

Participants were a “sub-group” of the prior focus

group study and therefore, they were again

interested users of the training program recruited

from the rural region in Upper Austria. After

showing design elements and mock ups, we asked

open questions about their first impressions towards

these mock-up designs with regard to six different

domains: interface design, design and appearance of

the training (presentation of the training person),

appearance of the avatar, voice of the avatar,

motivation/gaming design and interaction/gestures.

4.2 Mock up Study Results

Seven participants (5 male, 2 female; mean age 65)

took part in this study. All participants perceived

the interface design to be clear. Readability and font

size were satisfying to all participants. Only one

male participant (14%) had further suggestions for

the design of the menu buttons since he did not like

the form of an arrow: he suggested a square form

instead.

For the presentation of one’s own person in the

training program preferences differed significantly.

We presented three different design forms with and

without the nature background.

Figure 1: Person’s presentation design A.

There were two preferences (29%) for design A

(Figure 1) and design B (Figure 2), respectively,

and three preferences (43%) for design C (Figure

3).

Figure 2: Person’s presentation design B.

All participants had difficulties in correctly

interpreting the meaning of the colours of the

person’s presentation through all designs. Also the

different sizes of the bullets of the persons’

presentation in design A was not clear for the

participants. Through all designs there was no

overall preference for the neutral grey background

compared to the nature background.

Figure 3: Person’s presentation design C.

For the appearance of the avatar the participants

had very different views. We presented younger and

older avatars, as well as male and female ones. In

general, three participants (43%) preferred a

younger avatar (2:1/m:f) and four participants

(57%) preferred an older avatar (2:2/m:f).

Concerning the avatar’s voice, we presented

four different female and four different male voices

related to rate of speaking. There was no distinct

preference for a distinct voice but the participants

clearly preferred a slow pace.

Since the Train and Win program should also

increase the motivation of the older adults to

exercise, the participants were asked about their

impressions about five different designs for

feedback presentation of the training course. No

participants could interpret the meaning of these

designs correctly: Nevertheless, three participants

(43%) preferred the landscape motivation design

(Figure 4) because of the clear meaning of a

progress in the training. Two participants (29%)

found the idea of activated individual music after a

successful training stage interesting.

Figure 4: Landscape Motivation.

Since the interaction of the users with the

system in this training program will be based on

gestures, we also presented four different

possibilities for use of the program and interface to

the participants. The gesture “Six Buttons” was

clearly preferred by the majority of the participants

(4; 57%). Here the users had six different menu

boxes which they could select with their left or right

hand and confirm by closing their fist.

5 DISCUSSION USER STUDIES

In contrast to published literature (Brox et al., 2013;

Strand et al., 2014) and contrary to our

expectations, gamification elements were refused

by a majority of the participants in our study. The

low technology usage in our participants was

similar to some studies in literature: for example,

Charness and Boot (2016) reported about only 10%

of American older adults aged 65 and above who

use game consoles, such as Playstation or Nintendo

for example. According to De Schutter (2011),

older adults played PC-based casual games such as

puzzle games or digital versions of card/board

games, since these games do not demand for a high

cognitive effort of learning. As a consequence of

few experiences with game consoles and other

physical training related technologies, our

participants expected a traditional physical training

program related to their previous experiences

regarding sports. Hence, comparison of training

scores was also declined.

Further the high activity level of the participants

of the focus group has to be considered with regard

to the expectations for the training program as well

as the rural area they live in which facilitates

outdoor social group activities and might be another

aspect of explanation of the results of the discussion

group. The results of the focus group show the

diversity between older adults. Although all

participants are from the same region and very

similar in age, their attitudes, technology

experiences and needs for a training program differ

significantly and can only be addressed with a very

individual training program and well adapted user

interface design.

Individualization of design and exercises of the

training was relevant for all participants and was

already reported in similar studies (Skjæret et al.,

2016; Uzor and Baillie, 2014). Uzor and Baillie

(2014) also found a stimulating effect on

motivation, if training process and progress were

reported. The participants concluded that a physical

training program should also include various

aspects of a healthy lifestyle such as nutrition or

psycho-hygiene. Furthermore, there was a need for

a variety of exercises in order to keep motivation

high.

Expectations concerning design of the

representation of the own person in the training and

appearance of the avatar varied a lot. Preferences

regarding a female or male trainer should be

respected for motivational reasons. Concerning the

person’s representation in the program a long-term

study could show whether these preferences consist

over time. A limitation of our studies was that the

participants could not experience the representation

during an active training session. Thus, it could also

be argued that imagination was impeded and the

passive observation of the figure was not reliable

enough. Furthermore, the presented user studies

have limitations regarding the small sample sizes

and the lack of geographical variation of the

participants.

6 CONCLUSIONS

The reported studies aimed to assess users’ needs

and requirements for a physical training program

based on the Microsoft Kinect and an Avatar acting

as a virtual trainer. Results of both studies show that

the participants have very different ideas about the

physical benefits of the exercises and expect

improvement of various health related issues such

as nutrition or psycho-hygiene. Since one of the

objectives of the Train and Win project is to address

and implement various health related aspects, these

expectations of the participants will be met.

Focus group results and mock up tests clearly

showed that the participants refused gamification

elements of the training program. Development of

the training program has to consider the very

traditional expectations of the participants towards

the training and neglect typical exergaming

elements such as competition between participants

or graphical rewards.

Both user studies showed that attitudes, needs

and technology experiences differ significantly

among the participants. Consequently, some aspects

of the training program, such as exercises, design or

representation of the own person have to be

individually adapted to ensure high user acceptance

and use of the program.

Based on the results of these two studies, the

technical system will be developed. Within the

planned project, 30 participants will actively use the

training program at home for eight weeks. Each

training session will last about 30 minutes. An

evaluation study is planned to measure the

outcomes of the training regarding physical activity

and well-being of the older adults.

ACKNOWLEDGEMENTS

This project was partly funded by the Austrian

Research Promotion Agency (FFG, grant number:

7043062).

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