Asthma, characterized by persistent inflammation of the airways and limited airflow, is the most common chronic pediatric disease [1]. Worldwide, studies consistently report that 40%-55% of children with asthma have uncontrolled asthma in the outpatient setting, defined as frequent respiratory symptoms and exacerbations necessitating the use of health care resources [2-5]. Poor asthma control can compromise long-term lung function and increase the risk of exacerbations, which can negatively impact a child’s school attendance and participation in activities [1,6-8] and is a major source of stress for families [1,9]. Despite existing tools for asthma education such as targeted one-on-one asthma education and accessible web-based or paper-based asthma information, inefficient knowledge transfer and poor adherence to prescribed therapy remain major contributors to poor asthma control [1,6,10,11]. For example, studies have shown that 50% of adults and children who are prescribed daily asthma medications do not take them as recommended [1,11], and that poor inhaler technique is common, with 70%-80% of patients using their inhalers incorrectly [1]. A study focused on patients’ perspective of taking long-term asthma controller medication reported various barriers to adherence, including doubts about asthma severity, fears of addiction, and limited knowledge [12]. Thus, novel tools for asthma education are needed to ensure adequate asthma control.

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 [13]. The Chronic Care Model (CCM), a validated framework for the management of patients with chronic illnesses, has recently been updated to create the eHealth Enhanced CCM (eCCM), highlighting the potential benefits that eHealth could have for such individuals [14]. This model presents various components that impact the management of chronic illnesses and eHealth applications, which can contribute to improved outcomes [14]. More precisely, it has been suggested that eHealth tools such as telehealth and mobile health apps could be useful in self-management support, resulting in more engaged and empowered patients [14]. Moreover, the eCCM includes eHealth education as a component of chronic care management, stressing the importance of health literacy and eHealth training [14]. The eCCM equally highlights the importance of having a patient who is informed and activated and a practice team that is prepared and proactive, with productive interactions between these 2 actors also contributing to improved outcomes [14].

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 [14]. SGs are games that impart real-world skills, knowledge, or attitudes to the user through play [15]. They represent a cost-effective, accessible, unique, and dynamic approach within eHealth that can positively impact self-management support and eHealth education, which are 2 key components of the eCCM, through behavioral change by including simulation and management activities [14-17]. A systematic review of SGs in asthma education revealed that 90% of the children enjoyed them, and that most studies resulted in an improvement in the child’s knowledge about asthma [15]. However, the vast majority of the games failed to demonstrate significant changes in behavior and clinical outcomes, possibly because they were directed uniquely at the children and not their parents, despite parents playing a major role in the treatment of their children [15]. Furthermore, previous SGs mainly focused on information delivery rather than simulations of real-life scenarios, which are more likely to promote behavior change. Finally, existing SGs are web-based or desktop computer–based, and their effectiveness may be enhanced if they are designed as accessible mobile apps [15].

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 [2,18]. They represent different game genres, including action, role-playing, and simulation. This pilot study aims to evaluate the acceptability of these original bilingual (French and English) SGs and gather feedback to guide their further development by answering the following research question: what are the children’s and their parents’ perceptions of the role of SGs in the self-management of asthma?

A qualitative study with a consensual qualitative design and an embedded quantitative component [19,20] was used to explore children’s and their parents’ perceptions of the role of SGs in different aspects of asthma self-management. We chose a consensual qualitative design because we emphasized the agreement between members during focus groups and within the research team.

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 [21-23], the expertise of a qualitative researcher on our team, and the feasibility for a pilot study.

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 [14], which highlights important aspects of self-management and eHealth education in chronic illnesses. During the analyses, the members of the research team reached consensus to ensure validity and coherence of the results [19]. Specifically, the analytical process was divided into three major steps, including segmenting data from the transcripts into domains, abstracting data within the domains into core ideas, and performing a cross-analysis to develop themes across participants, which were agreed upon by the research team [20]. We used the software MAXQDA (version 12; VERBI Software) to support data analysis.

To ensure the validity of our study, we implemented various verification techniques throughout the analytical process [31]. By using multiple researchers for data analysis and different data collection methods (eg, questionnaires and focus groups), we were able to achieve analyst triangulation and methods triangulation, respectively, thereby ensuring a consensus among team members and maximizing the credibility and confirmability of our findings. In addition, peer debriefing was used to further establish credibility. Confirmability was further achieved by maintaining an audit trail and ensuring reflexivity by reporting biases, using multiple researchers, and using interviewers who are not involved in the care of the participants. Finally, we described the themes that emerged in this study by using quotes from the participants and their parents as evidence. As the individual interviews and group discussions were conducted in French, the quotes were translated to their English equivalents.

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 Table 2. The mean age of the participants was 10.3 (SD 1.5) years, and only 20% (1/5) of the participants were male. None of the participants had any asthma-related hospitalizations or emergency department visits during the 12 months before the study. The average time spent on playing video games each day was 30-60 minutes for 40% (2/5) of the participants. Mobile phones and different consoles were found to be the most used devices for gaming, with 60% (3/5) of the participants using each device.

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 (Figure 1). This model complements the original eCCM model by integrating key concepts pertaining to pediatric care and the role of SGs.

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 Figure 1.

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 [14]. The importance of efficient asthma education is equally emphasized in a systematic review of SGs, stating that education is an important factor in treatment because it promotes considerable ameliorations in asthma control and reduces emergency room visits and hospital admissions [15]. To address this heterogeneity in knowledge, the children and parents expressed that SGs could improve knowledge transfer through games. Indeed, as highlighted by a comparative study between asthma educational videotapes and asthma self-efficacy digital games, interactive media with active participation are more effective in improving self-management than traditional teaching methods such as educational videos [32]. Moreover, our participants appreciated the real-life scenarios presented in the games and expressed that such animations would provide them the knowledge to react accordingly in different situations. Similarly, parents considered the games to be a valuable source of information to build a strong base for a child with limited knowledge about asthma. These findings corroborate with those of other studies that have demonstrated how traditional educational methods have little appeal to children and the importance of using narratives as a novel educational tool [16,33]. Narratives have been shown to be a useful resource in promoting a great understanding of the impacts an illness can have and providing an emotional insight into the repercussions a disease can cause [33].

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 [14]. The eCCM also emphasizes that a patient must be activated, a term that equates to an individual’s level of skills, knowledge, and confidence in managing their disease [14]. As highlighted in our study, the model of a patient who is activated and empowered should also be extended to a child’s caregiver in pediatric care, given that caregivers play an essential role in their child’s treatment [15]. Although barriers to asthma self-management have been extensively discussed previously [12], we wanted to focus on how SGs could facilitate asthma self-management. Children and their parents expressed that SGs could provide an opportunity for the identification and management of real-life situations through games. SGs can aid in promoting self-management and patient empowerment through the social learning theory, which suggests that through self-modeling (ie, the players observe a character in the game who is a representation of themselves and who they control), the player is able to learn through his or her character and apply what they have learned to real-life situations [17]. In addition, a study concerning the application of health games to manage chronic pediatric diseases showed that, often, children with chronic health conditions experience low self-esteem and stigmatization from peers because of daily self-care and monitoring [32]. However, by presenting characters who have the chronic disease and who represent positive role models who achieve their missions in the SGs while simultaneously battling and managing their illness, children learn that their chronic disease can be overcome and that self-management is an achievable goal [32].

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 [7]. Children and parents expressed that SGs could provide an opportunity to play with others for support and shared knowledge. Indeed, both parents and children expressed an interest in playing the SGs presented in this study with each other, stating that this would also allow for more parent-child discussions about the condition. A study concerning the management of chronic pediatric diseases with health games found that 1 month after playing asthma self-management games, the children experienced more self-efficacy in talking with their friends about asthma and showed increased communication with their parents about their condition, illustrating how SGs can help strengthen a child’s support system [32]. Similarly, an inpatient study evaluating the impact of asthma self-management SGs revealed that, often, during gaming sessions, one child would explain asthma management strategies to another child, allowing both players to win the game together [32]. Therefore, SGs offer a unique, interactive, and enjoyable opportunity for children with asthma to learn and interact with their peers and parents.

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 [34].

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.