Keywords

1 Background and Motivation

Exercise- and physical activity-based games (exergame, henceforth) have recently received much attention from a variety of healthcare fields due to the game’s potential health benefits. Commercial exergame consoles requiring increased amount of physical activities, such as Nintendo Wii, Microsoft Kinect, and Sony Move, have been developed and occupied a significant share of worldwide video game market. Also, exergames have frequently been employed for rehabilitation and exercise purposes, including isometric muscle training [8], body balance training [2], as well as, exercise for adults with cerebral palsy [7] and for elderly [10]. Researchers have also designed and evaluated customized exergames in various usage contexts such as rehabilitation [4–6] and elderly socialization [9].

Among many potential beneficiaries of exergames, this study focuses on institutionalized older adults. According to the Center for Disease Control and Prevention statistics in 2010,Footnote 1 one out of three older adults falls. These falls often lead to severe disabilities, injuries, impaired function; more importantly, falls cause fear of falling among survivors, who as a result develop sedentary life-styles and lower quality of life. Sedentary lifestyle refers to a lifestyle that lacks physical activities or involves only irregular and infrequent activities, and is often called as “sitting disease.”Footnote 2 Although sedentary life style is not limited to institutionalized older adults, this lifestyle can be aggravated among institutionalized older adults, since they experience social isolation and a lack of resources to pursue physical activities (e.g., limited facilities for activities in the institution). Therefore, the benefits of exergames can be augmented for this population.

Despite the important health benefits exergames can provide, only a handful of previous researchers have investigated exergames [4, 5]; and none of them has employed systematic investigations. The previous studies employed small, cross-sectional experiments, each with less than 10 participants and focused on whether participants were able to play games in the same ways intended by developers. However, the previous researchers did not investigate whether playing exergames actually bring any health benefits to the players. As such, the primary motivation of this research is to examine whether exergames bring any health benefits to players, especially, institutionalized older adults to whom exergames may bring greater health benefits.

We suggest that the answer to our research is contingent upon the sustainability of physical activities that the exergames promote among older adults. Like any other physical activities that can potentially increase health among older adults, such as light walking and gentle stretching, health benefits of exergames will increase when individuals get engaged in the physical activities continuously and regularly rather than having a sudden surge in the activity level and quitting shortly thereafter. In addition, if health benefits of exergames will increase if the exergame increases the player’s confidence in his/her fitness level and thereby reduces the fear of falling/injuries, and, as a result, becomes transferrable to other activities in their real lives. In this case, the player will be able to overcome sedentary life style and may be able to lead more active lifestyle that has a long-term health benefits. As such, our second objective is to design exergames that promote sustainable and transferrable physical activities.

To increase sustainability and transferability of the exergames, we propose two factors: (1) game design that optimizes players’ flow states and (2) social features embedded in an exergame that increases players’ loyalty to the exergame. We suggest flow states because older adults, like any others, may be interested in playing exergames, for a few months due to the game’s novelty but they may lose their interests gradually. A commercial exergame, Wii Fit, for example, is well known for causing boredom among players after a few months. One of the primary factors that prevents boredom and increases enjoyment is flow state [1]. We suggest that the game should be designed in such ways that the difficulty levels get adjusted as a player progresses his/her activity level. In so doing, the exergame will be able to create and maintain flow statues among players. Also, social influence has been recognized as a positive influence on continued use of any information systems, according to UTAUT (Unified Theory of Acceptance and Use of Technology) [11]. Also, recent studies on social media has suggested a social feature embedded in a website creates a sense of community and thereby gravitates users’ voluntary participation and contribution [3]. Accordingly, we include a social feature to the exergame so that players can play the game together, which is postulated to increase their continued use of the exergame.

2 Research Questions and Model

2.1 Research Questions

The above motivations are manifested in the following research questions:

  • R1. What factors increase the continued use of exergames?

    • Flow state (immersion and engagement in games)

    • Social influence (created by the social feature embedded in the exergame)

  • R2. Do the exergames increase physical activities sustainably among institutionalized older adults?

  • R3. Is the physical activity level increased by exergames transferrable to other daily activities of institutionalized older adults?

  • R4. What health benefits do exergames bring to institutionalized older adults?

2.2 Research Model

We use a conceptual framework integrating UTAUT (Unified Theory of Acceptance and Use of Technology) and Flow. UTAUT explains factors that lead to continued use of technology above and beyond the initial acceptance [11]; one of the factors is social influence, which fits well with one of our research question. Flow explains user engagement and immersion in gaming experiences [1]. We integrate the two theories in order to identify the factors, such as social influence and flow state, which leads to continued use of the exergame (Fig. 1).

Fig. 1.
figure 1

Research model

Full size image

3 Game Design

3.1 Exergame and Interface Design

We adopt a ball squeezing play as a medium of online social-physical interaction (see Fig. 2). Ball squeezing is usually employed for arm and finger muscle rehabilitation, as well as considered as a habitual play. For a similar example in East Asian countries, walnut playing is a popular and widespread hand exercise for acupressure therapy. We intended to give players a positive and healthy sense through utilizing this inherently health-related activity.

Fig. 2.
figure 2

Ball squeezing (left) and walnut play (right)

Full size image

The design and implementation of the ball play consist of two parts: (1) Game interface and in-game social interaction and (2) Ball-based game controller.

3.2 Exergame Interface and Social Interaction Design

While playing the game, each player alternately takes a role of instructor. Instructor generates a sequence of grip patterns for five seconds, for example, she may grip the ball with her thumb and ring finger for three seconds, and then change the grip using her all fingers for two seconds. The movement of each finger is mapped into specific audible feedback using pre-recorded sound clips (e.g., ‘Do’ for thumb, ‘Re’ for index finger, etc.) During the play, the players can use items to disturb others’ activities (e.g., making other players blind for 2s) (Fig. 3).

Fig. 3.
figure 3

Game play screenshot

Full size image

There can be a variety of potential for creative play. For example, a player can instruct the grip pattern by following certain rhythm or riff, to make playful social experiences. In this case, audible feedback is also helpful for giving a sense of collaborative musical performance as well. Otherwise, another player may try to give a tricky grip pattern to others, such as holding the ball using index and little fingers only.

In the background, the gaming interface plays a cheerful and rhythmical music. The players can talk together online while playing the game, to share their emotions, as well as their everyday life. This social and physical interactive play naturally helps players overcome extremely inactive condition.

3.3 Game Controller Design

We design a squeeze ball game controller, featuring intuitive hand squeeze gameplay by incorporating sensors to monitor changes of shape and external force. It is able to connect to players’ mobile devices, such as smartphones and tablets, and role as a physical gaming interface for mobile games. We combined a soft form outside with a set of flexure sensors inside, and the sensors monitor the current shape of the ball (i.e., deformation, as shown in Fig. 4) and force from outside. A microcontroller and a wireless communication component with Bluetooth technology are in the ball, and we develop software logic to analyze data from the sensor and transmit it to players’ mobile devices.

Fig. 4.
figure 4

An example of squeezing motion (left) and corresponding deformation of a ball (right)

Full size image

4 Experiment Design

In order to examine health benefits that the above exergame has on institutionalized older adults, we will conduct a longitudinal study that involves series of experiments.

4.1 Data Collection Sites

Three-four retirement homes for senior citizens in Midwest region of the US will be our data collection sites. Also, in order to check their health indicators, we will collaborate with a large hospital in Midwest with a well-known senior healthcare center that provides health checkup services to older adults.

Because our goal is to assess sustainability and transferability of exergames and their impact on older adults’ health, we will conduct a longitudinal study for the duration of six months. In the first three months, the researchers and their assistants will visit selected retirement homes, ask older adults to play exergames once a week, and repeat this session once/week for three months (12 sessions in total). In the first 12 sessions, their health indicators, such as blood pressure, subjective pain levels, and depression/anxiety levels, will be constantly measured and recorded.

Upon completion of the first 12 weeks of data collection, we will observe whether participants continue to play the exergames (i.e., sustainability) and whether they get engaged in any other activities (i.e., transferability), for the other 12 weeks. During the second half of data collection, we will continue to measure their health indicators.

4.2 Experimental Design

The experiment employs 2 × 2 factorial design with a control group. Two factors are physical activity and social influence. Physical activity has two levels – non-adjusted activity level and adjusted activity level. These two levels are devised to text the impact of flow states on players. Specifically, the exergame we propose will have physical activity levels that are being adjusted depending on players’ progress. The more they play, the game will present a slightly more challenging activity level for the players to fulfill. Completion of one level will allow the player to move on to the next level. The second factor is social influence, which has two levels—no social influence (solo play) vs. social influence (co-play). In addition, we employ a control group in which participants are not asked to play any exergames (Fig. 5).

Fig. 5.
figure 5

Experimental design

Full size image

5 Summary and Conclusion

In this study, we propose a pressure-ball exergame as a means to improve health among institutionalized older adults who are most susceptible to sedentary lifestyles due to their social isolation and high likelihood of falls and physical injuries. As sedentary lifestyle causes severe health issues, such as high blood pressure, high cholesterol, weight gain, and depression and anxiety, it is important to keep these susceptible population engaged in mild physical activities regularly and constantly. The purpose of the proposed pressure-ball games, in this sense, is not to drastically increase their activity levels, which could potentially cause further injuries, but to motivate them to lead an active lifestyle by building their confidence in their fitness levels and by alleviating fear for physical activities. To measure benefits of the pressure-ball game, we propose two factors—sustainability and transferability of physical activities promoted by the pressure-ball game. In order to increase sustainability and transferability, we propose also two factors—players’ flow states and social feature. The former will be operationalized by equipping the game with an automatic level adjustment feature that tracks a player’s progress and increases or decreases the next level. The ever-changing difficulty level and the resultant challenges are postulated to create and maintain players’ flow states. The latter will be operationalized by a social feature embedded in the game that allows players to enjoy the game with others. Social interaction is known to be a significant influence on continued use of IS [11]. We will conduct a longitudinal study that involves a series of experiments over the six months period at retirement homes located in the Midwest region of the US with the help of senior healthcare team from a large hospital in the region. The experiment employs an incomplete factorial design with two factors—social influence and physical activity, each of which has two levels, and finally a control group to which no exergame will be provided.

As aging population in the US is growing rapidly, it is important than ever before to keep this growing population in good health. One of the most accessible yet challenged way to increase their health is to increase their activity level mildly to prevent them from developing sedentary lifestyle. The pressure-ball we propose involves a very mild exercise yet is equipped with automatically adjusted challenge levels and social features that have a high possibility to achieve this goal.