Development and usability evaluation of the mHealth Tool for Lung Cancer (mHealth TLC): A virtual world health game for lung cancer patients

Highlights

• Eight users confirmed mHealth TLC to be believable, clinic-appropriate and helpful.

• Emotionally charged content created concerns about use clinic settings.

• mHealth TLC users benefited from and were engaged with virtual world role-play.

• Users provided useful usability feedback, despite being non-patients.

• Best practice for health game development includes using expert game developers.

Abstract

Objective

To test the feasibility and usability of mHealth TLC, an interactive, immersive 3-dimensional iPad health game that coaches lung cancer patients toward assertive communication strategies during first-person virtual clinics visits.

Method

We observed players and conducted semi-structured interviews. Research questions focused on scenario believability, the impact of technical issues, transparency of game goals, and potential of mHealth TLC to decrease lung cancer stigma (LCS) and improve patient–clinician communication.

Results

Eight users confirmed mHealth TLC to be: (1) believable, (2) clinic-appropriate, and (3) helpful in support of informed healthcare consumers. Concerns were expressed about emotionally charged content and plans to use mHealth TLC in clinic settings as opposed to at home.

Conclusions

Although the dialog and interactions addressed emotionally charged issues, players were able to engage, learn, and benefit from role-play in a virtual world. Health games have the potential to improve patient–clinician communication, and mHealth TLC specifically may decrease LCS, and promote optimal self-management.

Practice implications

Process reflection revealed the need for health games to be created by experienced game developers in collaboration with health care experts. To prepare for this best practice, research institutions and game developers interested in health games should proactively seek out networking and collaboration opportunities.

Introduction

With the rise of technology in health care, the use of electronic games provides new possibilities for cost-effective and individually tailored health care interventions [1]. The advantages of virtual games include: (1) the ability to incorporate ethnic and cultural diversity [2] (e.g., allowing participants to select skin tones for their avatars), (2) increased patient access to information and support on demand [3] (e.g., access to online resources or pre-programmed education modules), (3) promotion of behavior change with positive feedback (e.g., points and awards) [4], and (4) the ability to provide information for personalized symptom management (e.g., integration of existing expert system diagnosis and recommendation software) [5].

Lung cancer patients report inadequate communication with physicians about important topics such as end of life care [6]. Stigma is one factor that contributes to poor patient–clinician communication and inappropriate medical referrals [7], [8]. Stigma is defined as blame or devaluation associated in this case with a diagnosis of lung cancer. Currently, there are no interventions that equip patients to manage experiences of lung cancer stigma (LCS) and improve patient–clinician communication. The Mobile Health Tool for Lung Cancer (mHealth TLC) is the first interactive, immersive 3-dimensional iPad health game that allows lung cancer patients to experience first person virtual visits with their clinicians. The aims of mHealth TLC are to decrease LCS, improve patient–clinician communication, and promote optimal self-management. mHealth TLC provides coached patient–provider communication techniques, opportunities for practiced stigma resistance, and patient-specific health information.

Health games are conceptualized as motivational play for adults and can influence social skills, self-perception, empathy, psychosocial functioning (e.g., self-confidence and achievement motivation), and cognitive skills (e.g., attention, planning, and creativity) [9]. The theoretical basis for mHealth TLC draws from gaming, virtual reality, and communication research to create a safe environment where lung cancer patients can be informed and motivated, and can practice self-management with virtual providers.

Throughout the trajectory of the cancer experience, patients are exposed to both physical and psychological discomfort that can decrease motivation toward self-management [9]. Play promotes motivation through the incorporation of voluntary engagement and pleasure, independent of external rewards [10]. In addition, play is a means of stress management and has a key role in helping patients manage distasteful or shameful aspects of their illness [10]. Role-play fosters increased understanding of various social roles and encourages empathy.

Virtual environments are an ideal platform for the promotion of healthy behaviors [11], [12]. Immersion plus interaction constitute the basis for virtual reality. With immersion, players become motivated to proceed through the game's obstacles and objectives [13]. Replacement of a normal text interface with an avatar – a visual “manifestation of self in a virtual world” (p.30) [14] creates more arousal, trust, and commitment and allows the user to practice interactions with a persona in a virtual world and “engage in… imaginary experiences that transcend the actual world in which they live” (p. 255) [15]. Advantages of virtual worlds include: the ability to carry out tasks that could be difficult in the real world, possibilities for continuing and growing social interactions, and adaptability to user needs [16]. Virtual reality interactions are effective approaches to behavior change for both cancer patients and older adults [17], [18].

Similar to gaming's focus on motivation, communication scholars have noted that interventions to improve communication should address motivation, knowledge, and action [19], [20]. Communication competence theory purports that success as a communicator requires both capacity (i.e., knowledge of communication skills) and adaptability (i.e., the ability to be a nimble participant, a quality gained through the action of practice) [21]. The link between cognition (i.e., knowing what to do) and behavior (i.e., doing) is facilitated through practice and vicarious learning. Patient interventions that use modeling and rehearsal as pedagogical strategies to transmit knowledge and encourage action through practice tend to be the most effective; health games promote success through modeling and rehearsal [22].

The process of aging changes interactions between cognitive and sensory motor aspects of behavior. Older adults may adapt to these changes by focusing cognitive resources serially, for instance by stopping conversation while putting on shoes [23]. This strategy of approaching tasks serially may preclude older adults from getting the information that they need in a clinic setting when they are being asked to perform sensory motor tasks, e.g., “follow me”, or “take a deep breath”. An additional layer of psycho-cognitive difficulty is introduced with stigma.

Within this context of serial cognitive resource allocation, gaming provides older adults with opportunities to practice parallel processing of everyday tasks. Interactive games that improve psychological health and cognitive functioning of older adults have demonstrated a positive impact on self-management and behavior change [24], [25]. The Center for Technology and Aging reports that for older adults, health game interventions reduce hospitalizations and costs, increase patient satisfaction, and improve self-management and coordination between patients and clinicians [26].

A few interventions have been evaluated with positive results, most with a focus on physical activity and cognition. Physical, interactive fitness games, “exergames,” have demonstrated benefits for older adults. Pre-post assessments of a Window's-based Kinect TM exergame intervention with 24 older adults (71+) showed leg muscle and joint improvement, but no improvement in functional balance [27]. An RCT assessment of another exergame, the Nintendo Wii Fit, demonstrated that compared to usual exercise provided at retirement homes, the Wii Fit group obtained better balance (left single leg), flexibility (lateral reach), and gait speed [28]. From a cognitive perspective, an RCT of Lumosity showed that participants experienced significant improvements in reaction time, attention, visual memory, and wellbeing. However, neither working memory nor executive control was shifted by the intervention [29].

A recent study of technology adoption behavior by elderly users found that if older adults perceive enough personal utility, they are eager to participate in new digital technology [30]. As of 2014, more than half of older adults go online (59%), and over three quarters of older adults use cell phones (77%) [31]. However, health game usability issues related to sight or disability [31] can be a major concern for this demographic [24], and errors arising as a result of poor usability can hamper efficient learning [32].

Evidence exists that health game interventions help cancer patients access health information and facilitate informed decision making [33]. Time After Time, a health game for older men with localized prostate cancer [24], was found to be feasible and acceptable as an aid for older patients. Although targeted to adolescent cancer patients, Re-Mission, a health videogame, is associated with improved treatment adherence, self-efficacy, and health knowledge [34], [35]. Studies have documented the association between neural positive reward mechanisms activated by playing Re-Mission and positive attitudes toward chemotherapy [36].

Lung cancer kills more men and women, and is associated with greater levels of psychological distress, than any other cancer [37], [38], [39]. Lung cancer stigma is a perceived health-related stigma, defined by experiences of exclusion, rejection, blame or devaluation resulting from anticipation of a negative judgment related to a lung cancer diagnosis [40]. The judgment inherent in any health-related stigma is medically unwarranted and may adversely affect health status [41].

Lung cancer stigma is a factor in the psychological and physical health of lung cancer patients [42], [43], [44]. LCS negatively impacts patient outcomes such as quality of life [43] and symptom severity [43], [44]. Clinician–patient communication has been found to be inadequate, especially for issues related to prognosis, symptom management, mental health, and end of life care [6]. Studies have shown that physicians believe type of cancer is not a factor in referral decisions, however, compared to breast cancer, lung cancer patients are less likely to receive appropriate referrals [8]. In addition, our previous work suggests that medical interactions may trigger LCS through activation of patient feelings of inferiority and loss of control [45].

Stigma resistance is a protective factor in other health-related stigmas (e.g., inflammatory bowel disease [46], HIV/AIDS [47], [48], [49], and schizophrenia [50]), but is unexplored in lung cancer. External interpersonal support (such as that received from support groups and supportive family [49], and empathetic care) contributes to stigma resistance [50]. A meta-analysis of mental illness stigma interventions has shown measurable reductions in public stigma, but did not change perceptions of stigma on the part of patients [51]. Considering this, there is room for patient-centered interventions that attempt stigma mitigation.

mHealth Tool for Lung Cancer (mHealth TLC) is a technology-based stigma reduction intervention. Lung cancer patient “players” arrive at a bus stop outside a cancer center, where they are met by a guide or “coach”. The coach presents himself as a knowledgable friend (neither patient nor provider) who offers explanation and support and who may be called upon for advice or clarification throughout the experience. Many games start in the form of narrative to draw players into the game world [52]; narrative increases motivation and immersion [9], [13]. The coach in mHealth TLC provides the narrative (i.e., story of a lung cancer patient who previously visited this virtual clinic and achieved optimal health literacy and self-management). To continue the immersion, players are given choices about their physical and verbal responses to stimuli throughout the game, and encouraged to return for more practice over the course of four “visits”.

The goal for players is to choose the more assertive responses to help acquire the most information in order to manage their lung cancer and advance through the clinic landscape. Players experience successful navigation of a clinic visit through increasingly complex situations, giving them practice addressing issues and asking questions, which thereby develops skills they can use in their real world clinic visits.

After initial interactions with the coach, players know that during the game they will: (1) interact with three oncology staff (i.e., the receptionist, medical assistant, and provider); (Fig. 1) (2) navigate through the clinic and acquire all of the information they need to manage their lung cancer care; (3) access the coach for help, as needed; (4) be provided opportunities to select from a range of verbal responses (e.g., aggressive, assertive, and passive), and thus tailor their communication strategy iteratively during play.

In order to create realistic dialog for players, coach, and non-playing characters, we used qualitative data from our previous studies with lung cancer patients [45]. Patients’ stories of experiences of stigmatization and attempts at self-management informed both narrative and dialog. Stigma, blame, and self-blame are addressed in the interactions, and information about the role of addiction, social/cultural factors, and tobacco industry influence on smoking behaviors are highlighted.

The goal of usability testing was to identify functional and conceptual problems, observe user performance, and determine user satisfaction. The research questions were: (1) Were game scenarios believable and potentially valuable to end-users? (2) What were the impacts of technical issues on player acceptance and tolerance of the game? (3) Were game goals transparent to participants and, if not, what were the perceived game goals? and (4) Did participants think that mHealth TLC could provide intended game outcomes to future players (i.e., better communication between patients and providers)?

The development team determined that this game version was too incomplete to test with patients. Usability testing was performed to determine whether the project should be developed in this platform, or continue in a different virtual environment. The development team worried that lung cancer patients might be further distressed by the emotional material contained in the game. For these reasons, we chose a small sample of locally recruited usability testers to gain insights that might direct further development.