This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Pediatrics and Parenting, is properly cited. The complete bibliographic information, a link to the original publication on https://pediatrics.jmir.org, as well as this copyright and license information must be included.
Asthma is the most common chronic pediatric disease. Despite existing tools to manage asthma, 40%-55% of children with asthma experience uncontrolled asthma. Serious games (SGs) represent a novel approach in promoting asthma education and self-management for children.
In this qualitative pilot study with an embedded quantitative design, we aim to use focus groups and questionnaires to describe the perceived role of SGs in different aspects of asthma self-management by children and their parents. These aspects include asthma perception and knowledge, the impact of asthma and barriers to asthma self-management, and the support system for asthma self-management.
A total of 5 children with asthma and their parents were invited to participate in an organized gaming session. Children and their parents completed a pregaming questionnaire on their medical history and asthma knowledge. Then, they were invited to test 4 original SG prototypes, after which the children answered a postgaming questionnaire on their asthma knowledge and perception of the SGs. Children and their parents subsequently participated in parallel focus groups, which were video-recorded or audio-recorded, transcribed verbatim, and analyzed by reaching consensus among members of the research team.
The mean age of the children was 10.3 (SD 1.5) years, with 20% (1/5) of the children being male. Qualitative data from the transcripts were coded into three separate domains: asthma self-management perception and knowledge, impact of asthma and barriers to asthma self-management, and support system for asthma self-management. We specifically explored the perceived roles of SGs within each domain. A key takeaway message was identified for each of these three domains: heterogeneity of asthma knowledge and the ability of SGs to encourage knowledge transfer through games, consequences and limitations of asthma and the ability of SGs to allow for identification and management of real-life situations through games, and insufficient support system and the ability of SGs to encourage playing with others for support and shared knowledge.
Our pilot study explored the role of SGs in the self-management of asthma, as perceived by children and their parents. Our findings support the acceptability of SGs in asthma education and self-management in pediatrics and the necessity for future development in this field.
Asthma, characterized by persistent inflammation of the airways and limited airflow, is the most common chronic pediatric disease [
Recent and ongoing technological advances have allowed the field of eHealth to prosper and evolve greatly. eHealth is the cost-effective use of technologies in various fields of health, namely, health education [
Although the eCCM focuses primarily on implementing eHealth tools, such as the use of internet for health information, mobile health, telehealth, electronic health records, and personal health records or patient portals, it does not specifically address the role of serious games (SGs) in health or in chronic illness management [
To evaluate how SGs can be integrated into the asthma management framework, we build and, in a pilot study, evaluate 4 open-source SG prototypes focused on recognizing asthma triggers and symptoms and taking appropriate actions during an asthma exacerbation or as part of control therapy. These games are developed to provide a novel technique to promote self-management of asthma in children, which is a key aspect of asthma action plans [
A qualitative study with a consensual qualitative design and an embedded quantitative component [
The study obtained approval from the research ethics boards of both the Sainte-Justine University Health Center (ID 2019-2075) and Concordia University (ID 30010592). Written informed consent and written or oral assent for the study and video-recording or audio-recording were obtained from the parents and from age-appropriate children, respectively.
We identified children meeting the eligibility criteria through the appointment list and a chart review, and the families were consecutively approached by the research team for participation at the respiratory medicine or asthma clinic of the Sainte-Justine University Health Center, a pediatric tertiary care center. Participants were children (1) aged 8-12 years inclusively, (2) with physician-diagnosed asthma, (3) who were on a daily controller medication, and (4) who understood and spoke French or English. We excluded children with chronic conditions other than asthma, such as cardiovascular diseases, neuromuscular disorders, or developmental delay. The targeted sample size of this study was 14 children and one of each of their parents. This sample size was based on previous literature using focus groups in pediatric health care research [
Pregaming questionnaires were administered separately to both parents and children upon their arrival. The pregaming questionnaires included questions pertaining to previous gaming experience (children), asthma perception (children and parents), asthma knowledge (children and parents), and medical history of the child (parents). Asthma perception was assessed through several statements about general health and asthma using a Likert scale. The asthma knowledge questionnaire included true or false questions pertaining to their knowledge of asthma. In the absence of a well-validated asthma knowledge questionnaire, we created this questionnaire based on previous studies [
Description of the 4 games used in this study.
Name of the game | Game description | Educational objectives | Time allotted to play (minutes) |
Asthmonautes | A game in which the child navigates through different scenarios and interacts with 9 characters to learn about asthma symptoms and management [ |
Understand asthma symptoms and management | 30 |
Lung Launcher | A game in which the character encounters different asthma triggers (customizable to the child) and the child must find the correct preventive method to address each trigger [ |
Identify asthma triggers and learn how to address them | 4 |
Asthma Heroes | A game in which the player interacts with several characters to learn about their symptoms, treatment, and context and collects objects to help them manage their asthma [ |
Understand asthma symptoms and management | 30 |
Bloïd | A game in which the player uses a breath-actuated sensor as an input device to guide a spacecraft and destroy meteorites in its path [ |
Be aware of own breathing | 4 |
We conducted semistructured focus groups with children and parents separately. Individual interviews were conducted on one of the study days, as there were only 2 children and 2 parents present. Of note, the interviewers were not involved in the clinical care of the participants and were unfamiliar to them. The topic guides used to collect data considered the inclusion of probing questions that were used accordingly to obtain more detailed responses. The topic guide for the children’s focus group included themes such as asthma in general, gaming experience, practical implications the games could have on their health including benefits and risks, and the potential of playing SGs at home. The topic guide for the parents’ focus group revolved around asthma management and challenges, available resources to help overcome their challenges, and the acceptability of SGs in health. The interview and focus group times ranged from 16-35 minutes. We aimed to achieve consensus among the participants during the focus groups.
We used the predetermined questionnaires for the quantitative part of the study and predetermined discussion topics to evaluate the topics of interest qualitatively. Then, the recordings were transcribed verbatim. For confidentiality purposes, all personal information was removed from the transcripts and participants were allotted a study identification number.
We described the participants’ characteristics and information pertaining to their asthma. The analysis of the qualitative data was guided by the eCCM [
To ensure the validity of our study, we implemented various verification techniques throughout the analytical process [
The targeted sample size of this pilot study was 14 children and one of each of their parents. We approached 37 potential participants and 14 (38%) families agreed to participate. Reasons for declining participation included lack of time, living far from the hospital, and scheduling conflicts. On the day of the focus groups, owing to unpredictable cancellations (extreme weather and scheduling conflicts), the final sample size was 36% (5/14) of the children and 6 parents (2 parents were present for one of the children). We invited participants to attend one of the 2 half-day sessions organized at the Sainte-Justine University Health Center.
Baseline characteristics of the participants are presented in
Baseline characteristics of the children with asthma included in this analysis (N=5).
Characteristics | Values | |
Age (years), mean (SD) | 10.3 (1.5) | |
Sex (male), n (%) | 1 (20) | |
Parental report of age of asthma diagnosis (years), mean (SD) | 1.9 (1) | |
Child report of age of first asthma exacerbation (years; for nonmissing data; n=3), mean (SD) | 2.2 (0.8) | |
Asthma-related hospitalization during the past 12 months, median (IQR) | 0 (0) | |
|
||
|
Never | 1 (20) |
|
0-30 minutes | 1 (20) |
|
30-60 minutes | 2 (40) |
|
60-90 minutes | 0 (0) |
|
90-120 minutes | 0 (0) |
|
>2 hours per day | 1 (20) |
|
||
|
Mobile phone | 3 (60) |
|
Tablet | 2 (40) |
|
Computer | 2 (40) |
|
Console | 3 (60) |
The analysis of the transcripts from the individual interviews and group discussions occurred in 3 major steps and was guided by the following research question: what are the children’s and parents’ perceptions of SGs in the self-management of asthma? The transcripts were analyzed by a primary research team composed of 4 coders (NS, AV, FB, and SMT). Transcripts were first coded into 3 major domains, or topic areas, by one of the coders (NS) and then, verified by the remaining coders on the research team (AV, FB, and SMT). The domains reflected various components of the perceived reality of asthma by children and parents. They included (1) asthma self-management perception and knowledge, (2) impact of asthma and barriers to asthma self-management, and (3) support system for asthma self-management. The data in each domain were abstracted independently into core ideas by 4 coders (NS, AV, FB, and SMT), focusing on the role of SGs within each domain, as perceived by children and parents. Then, the 4 coders worked together to perform a cross-analysis of the core ideas within the domains to generate common themes on the roles of SGs. The team discussed until consensus was achieved. Analysis was guided by the eCCM. After analysis, a visual model was created, illustrating the key interactions between asthma and SGs, as perceived by children and parents (
Visual representation of the main results obtained in this study. Our results demonstrated a triangular relationship between a child with asthma, their parent, and the potential role of serious games (SGs) on the 3 domains of asthma management evaluated in this study. The major overarching issues identified during discussions with parents and children, respective to each domain, are also illustrated.
Study domains and corresponding themes identified from interviews and discussions with children and parents.
Domain | Themes | |
|
Children | Parents |
1–The role of SGsa in asthma self-management perception and knowledge |
Knowledge transfer achieved through the games |
Potential of learning about asthma through games and knowledge transfer Gain of knowledge depends on experience and onset of asthma |
2–The role of SGs in addressing the impact of asthma and barriers to asthma self-management |
Knowledge on self-management through games |
Knowledge on self-management through games Utility of games at asthma diagnosis Games as a possible tool to evaluate ongoing asthma control |
3–The role of SGs in the support system for asthma self-management |
Asthma awareness through SGs Openness to further discuss asthma with parents through games Interest and utility of playing the games with peers |
Importance of parent and child playing together Interest and utility of playing the games with peers |
aSG: serious game.
This domain included different themes pertaining to the role of SGs in children’s and parents’ asthma self-management perceptions and knowledge. On the basis of the pregaming questionnaires on asthma perception, we already noted some inconsistencies in the children’s perceptions of their ability to manage their asthma. Only 40% (2/5) of the children agreed that they were able to recognize an asthma crisis, whereas 60% (3/5) of the children agreed that they were able to control their asthma adequately, and 80% (4/5) of the children agreed or strongly agreed that their asthma crises could be prevented. Parents were more confident about asthma management, with 80% (4/5) of parents agreeing that they knew how to manage their child’s asthma crises and 80% (4/5) of the parents agreeing or strongly agreeing that they knew when to give each inhaler to their child.
Regarding asthma self-management knowledge, some parents expressed having a divergent perception of asthma severity as compared with that of medical professionals. This is illustrated by the following quote from a parent when questioned whether they were interested in participating in the game with their child:
No, because for us, the only thing that gets our attention is when he isn’t breathing well or when he has allergies. Otherwise, everything else for us is normal. Maybe we lack sensitivity.
In addition, parents described the contrasting perceptions of asthma management between parents and their children with asthma, exemplified by the following quote:
Sometimes it’s like she thinks that she takes too many [medications] and she tries to say ‘Oh, I’m going to tough it out, I am still able to breath well’ before taking her pumps. And I tell her, ‘Don’t do that, take it [your pumps] right away’. And she says ‘No, no. I can handle it myself.
We also explored data on children’s and parents’ general asthma knowledge in this domain using quantitative data from the asthma knowledge questionnaire. Results from the pregaming questionnaires suggested that participants had a fair amount of asthma knowledge before participating in the study. However, some of the questions in the pregaming questionnaires were unanswered by the participants (
On the basis of current scientific knowledge of asthma, several false beliefs were identified among the parents, including that inhalers could lead to dependence or addiction (1/5, 20% agreed), it is not good for children to use the inhaler for very long (3/5, 60% strongly agreed or agreed), children should use asthma medications only when they have symptoms (1/5, 20% strongly agreed; 1/5, 20% neither agreed nor disagreed), inhalers should be used directly in the mouth (2/5, 40% agreed), and controller medications can be used intermittently (3/5, 60% strongly agreed or agreed). In contrast, parents understood other concepts well, with 80% (4/5) of them disagreeing that children with asthma should not exercise or participate in physical education class and that mild asthma attacks can be managed outside of emergency departments. Through the discussions with the parents, we also identified varying degrees of asthma knowledge present among them. Specifically, some parents acknowledged their reluctance to administer prescribed medications unless their child was acutely ill, as illustrated in the following quote:
As long as I can survive without medication, I don’t take any. But, when I see him [the child] suffering sometimes when he has his crises and everything, I am obliged. We even neglected the pump because I am anti-Ventolin because it’s not good for his health in the long term.
In contrast, several parents viewed their children’s asthma specialists as important resources in the management of asthma.
Subsequently, we explored how children and their parents perceive SGs in asthma self-management and knowledge and extracted key themes from these data. After analyzing the discussions with the children, we concluded that they were able to identify the game objective correctly and that
Child knowledge of asthma before and after playing the serious games based on true or false questions (N=5).
Child knowledge of asthma–questions | Before game | After game | Discrepancy | |||
|
Correct answers, n (%) | Nonmissing data for pregaming questionnaire, n (%) | Correct answers, n (%) | Discrepancies between questionnaires, n (%) | ||
Lots of children have asthma | 5 (100) | 5 (100) | 5 (100) | 0 (0) | ||
People with asthma can drink milk and eat yogurt | 5 (100) | 5 (100) | 5 (100) | 0 (0) | ||
Having the flu can cause an asthma attack | 2 (50)a | 4 (80) | 4 (80) | 2 (40) | ||
Smoking is OK for people with asthma | 5 (100) | 5 (100) | 5 (100) | 0 (0) | ||
People with asthma become hooked on their asthma drugs (cannot get off them) | 0 (0) | 3 (60) | 1 (20) | 1 (20) | ||
If you have asthma now, you will have asthma forever | 4 (80) | 5 (100) | 5 (100) | 1 (20) | ||
An asthma attack is caused by redness and swelling in the airways of the lungs | 3 (75)a | 4 (80) | 4 (80) | 1 (20) | ||
Most children with asthma are smaller than other children | 4 (100)a | 4 (80) | 5 (100) | 1 (20) | ||
Asthma can be spread from person to person | 5 (100) | 5 (100) | 5 (100) | 0 (0) | ||
Medicines that keep asthma from happening should be taken every day | 5 (100) | 5 (100) | 5 (100) | 0 (0) | ||
The blue puffer (inhaler) should be used when a person has an asthma attack | 4 (80) | 5 (100) | 5 (100) | 1 (20) | ||
Asthma happens more at night | 3 (60) | 5 (100) | 3 (60) | 0 (0) | ||
An asthma attack can happen suddenly without warning | 5 (100) | 5 (100) | 5 (100) | 0 (0) | ||
When asthma is OK, all medicines can be stopped | 4 (80) | 5 (100) | 4 (80) | 0 (0) | ||
With the right treatment, a child with asthma can live a normal life | 4 (100)a | 4 (80) | 5 (100) | 1 (20) | ||
Children with asthma can play sports | 4 (80) | 5 (100) | 4 (80) | 0 (0) | ||
The orange inhaler controls asthma | 4 (80) | 5 (100) | 5 (100) | 1 (20) | ||
The blue inhaler helps with an asthma crisis | 5 (100) | 5 (100) | 5 (100) | 0 (0) | ||
The blue inhaler opens the airways in the lungs | 3 (60) | 5 (100) | 5 (100) | 2 (40) | ||
The orange inhaler prevents asthma crises | 4 (100)a | 4 (80) | 5 (100) | 1 (20) | ||
The blue inhaler helps the breathing during an asthma crisis | 5 (100) | 5 (100) | 5 (100) | 0 (0) |
aSample size, n=4, owing to missing data.
The role of SGs on asthma perception and asthma knowledge as perceived by the parents was identified using the asthma perception questionnaire before playing the SGs and through the discussions with the parents. The questionnaire revealed that 40% (2/5) of parents agreed that health-related video games can help their child understand or manage their asthma, whereas the remaining parents neither agreed nor disagreed. Moreover, 100% (5/5) of the parents strongly agreed or agreed that they would accept that their child plays health-related video games at home. The themes extracted from the discussions with the parents illustrated similar results. Similar to children, the theme
With the game, I think that she [their child] would realize ‘Oh no, I think that maybe I should take it [medication] as soon as possible’ rather than waiting.
In addition, parents expressed that the
This domain included different themes pertaining to the roles of SGs in addressing the impact of asthma and barriers to asthma self-management, as expressed by children and parents. Regarding the impact of asthma, the daily burden of asthma was a recurrent topic expressed by children. This is illustrated by the following quotes:
For me it’s also sports. I tire out before the others.
We are in the middle of a game and I have to stop. I have to stop to take my pumps. Sometimes I’m scared that I’m a nuisance to my team.
Although the children recognized the importance of medications in controlling their asthma, they also identified poor adherence as a barrier to asthma self-management.
The impact of asthma and barriers to asthma self-management were also explored with the parents. Parents also referred to the daily burden of asthma on their child and family, as illustrated by the following quote:
She spends every night out of breath. She is always gasping for air. She is always congested. There is no specific season that she is suffering, but it’s almost every day. We almost always go to see the doctor. We have been in follow-up for years, but I see that things haven’t changed. On the contrary, it’s getting worse and worse.
Parents expressed fear and anxiety related to exacerbations and, as identified in domain 1, showed different perceptions of the severity of their child’s asthma. These were identified as barriers to asthma self-management. Another barrier is poor adherence secondary to burden of medications. Discussions with the parents revealed that forgetfulness was often a specific cause of poor adherence, along with fear of side effects associated with medication intake.
Children and parents explored the role of SGs in the impact of asthma and barriers to asthma self-management, particularly the identification of real-life situations within the games. Specifically, children acquired
Even if you are, for example, asthmatic, you can still do sports, but you have to take your pumps first before doing the sport.
Interestingly, children expressed being more aware of and able to focus on their breathing through the game, Bloïd, which uses a breath-actuated game controller. Similar themes were identified from the discussions with the parents, who identified acquired
It [the SGs] was a practice even for me because I always mix up the blue and purple [pumps]. I ask myself ‘Which does what?’ And at a certain point [in the game], it was more visual for me and now the diagram is engraved in my brain.
In addition, parents suggested that games may be particularly
This domain includes different themes pertaining to the role of SGs in the child’s support system for asthma self-management, as perceived by children and their parents. Children expressed feeling alone with their asthma
Both parents and children identified the beneficial effects of SGs on their support systems for asthma self-management. Children highlighted how SGs could allow players to feel less alone with their asthma by increasing
Maybe they would learn more with us. Most of the time, they are the ones that give me advice because they listen to the doctors more. They know a little more, because even if they aren’t doctors, they know more about this subject. But we could interact at home and talk about what we thought [about the games].
A similar theme,
I don’t really play video-games, but I still learned things, not that I didn’t know, but that maybe I hadn’t absorbed. By playing, watching and participating with my daughter, I learned certain things.
Parents appreciated the parent-child collaboration through gameplay, as it allowed them to be more aware of their child’s asthma self-management skills. Both children and their parents separately identified an
In this pilot study, we conducted qualitative individual interviews and group discussions with participants and their parents to evaluate the perceived role of SGs in asthma management and knowledge transfer achieved by these games. Our study identified the following domains, or components, that are key to asthma management: asthma self-management perception and knowledge, the impact of asthma and barriers to asthma self-management, and support system for asthma self-management. Within these domains, our team consensually identified various themes pertaining to the perceived role of SGs in the given components. In the following sections, we summarize our findings by identifying an overarching issue for each domain and explaining how SGs can be used to address this issue. The results are summarized in
In the domain of asthma self-management perception and knowledge, the heterogeneity of asthma knowledge, which is related to asthma perception, was identified as the overarching issue for both children and parents. The discussions with the children and parents revealed that some participants had adequate knowledge about asthma, including trigger recognition and different medications, whereas other participants had poor understanding of asthma and even expressed several false beliefs. Specifically, some children were unaware of resources other than the inhalers that were available to them, such as books or educational websites. Several parents not only expressed being in denial of the severity of their child’s condition but also displayed numerous misconceptions about asthma. The importance of health literacy, the capacity to understand and manage one’s own health, is a component emphasized in the eCCM and is essential for the proper management of chronic diseases and the adequate use of eHealth services [
Within the domain pertaining to the impact of asthma and barriers to asthma self-management, the consequences and limitations of asthma surfaced as the overarching issue for both children and their parents. Despite having access to regular medical care, children and parents expressed being subject to the consequences of the child’s asthma, specifically regarding activity limitation and fear and anxiety related to asthma exacerbations. According to the eCCM, having a patient who is empowered and in control of their illness is crucial to improve health outcomes [
Finally, in the domain related to support system for asthma self-management, we identified an insufficient support system as the overarching issue among children and parents. In the case of children, family implication in the child’s condition is essential, an idea that was equally mentioned by the children in our study, who viewed their parents as a source of support. Notably, effective parent-child collaboration in managing a child’s asthma is a key element in improving medication adherence and positive health outcomes [
Our study has numerous noteworthy strengths and limitations. First, compared with previous studies in the field, the originality of our study stems from the inclusion of both children and their parents in the gaming sessions and discussion groups, allowing for the comparison and contrast of thoughts and perceptions. This is particularly important given the unique parent-child interactions in pediatric chronic disease management. Second, we based the development of our games on the theory of co-design, adapting our games based on the comments and input from users throughout their development. Thus, the versions presented to participants in this study have already taken the input of patients with asthma into account, making them even more pertinent to the study population. Third, the analysis of our qualitative data was achieved through consensual qualitative research, a research method that incorporates various validation methods to ensure the validity of the results (ie, member checking and discussing until agreement was reached).
However, despite these validation methods, a possibility of subjectivity in our results remains, emphasizing the need for more extensive member checking. The small sample size and inclusion of patients followed at a pediatric hospital may reflect potential selection bias and limit the generalizability of our results. Specifically, the feedback gathered from the limited sample of children may not reflect the perspectives of other children with asthma. In addition, owing to the limited number of participants, we were unable to conclude any statistically significant changes in terms of pregaming and postgaming knowledge from the participant questionnaires. Thus, a large study is needed to better evaluate the impact of these SGs on asthma knowledge and to collect additional feedback from players. Given the design of the study, the time allotted to play was limited to a total of approximately 60 minutes, which may have affected the depth of the evaluation of the game by participants. Although we were able to gather valuable feedback, further studies are needed to evaluate the acceptability of the games in different settings (eg, at home or during free play).
Following this study, feedback from children and parents was integrated into the games, Asthma Heroes and Asthmonautes. Both games were translated and are now accessible in French, English, Spanish, Chinese, Russian, Arabic, Portuguese, Japanese, Vietnamese, Korean, Farsi, Turkish, German, and Italian. In addition, our team conducted a second study, where 158 children tested a game played using a breath-activated controller, which enables the assessment of one’s breathing capacity [
In conclusion, through discussions with children with asthma and their parents and consensus within our research team, we identified various themes pertaining to how SGs can address some of the perceived barriers related to asthma self-management. Although our pilot study was based on a limited number of participants and further studies are required to confirm our results, our findings support the acceptability of SGs by both children and their parents and their potential role in asthma education and self-management. The numerous potential benefits of SGs in various aspects of asthma management highlight the necessity for future developments in this field.
Chronic Care Model
eHealth Enhanced Chronic Care Model
serious game
The authors would like to thank AV and Valentin Gomez, who initiated the collaboration on games for asthma at Sainte-Justine hospital; Kevin Cottier, Marc-Arnaud Cotting, Guillaume Dévaud, Flavien Knuchel, Nibe Mbumba, Kevin Piccand, Awi Piers, Amélie Suter, Alexandre Wegmuller, and Nicolas Wenk, who designed and developed
FB and YG cofounded the Breathing Games commons. FB is a chairperson of Breathing Games Association. The development of the games was led by Breathing Games.