43 Design of the persuasive game ‘Ademgenoot’ 2 Intention Upon onboarding the app, Ademgenoot offers a brief instruction on inhaler technique and the difference between maintenance and reliever inhaler and its effect on the lungs. Motivational Interviewing techniques are included through the use of personal goal setting and creating a commitment. After the onboarding screens, users are offered a six-week challenge, linked to a personal goal. Upon accepting the challenge, users enter the game world. Action Use of narrative and game elements Ademgenoot employs the use of a narrative and metaphors to motivate users to adhere to their maintenance inhaler. The narrative involves a cloud-like character named Brad, whose mission is to reach a treasure island, which represents the user’s personal adherence goal. To do so, Brad must cross over water. Connected to the EDM, Brad is able to “safely” cross the water when inhaler use is detected. However, when inhaler use is not detected he falls into the water. Therefore, it is the patient’s responsibility to create bridges for Brad to safely cross the water by adhering to the inhaler regimen. The user is also confronted with the possibility of Brad falling into the water and drowning when not adhering to the regimen. In the scenario of one missed dose, Brad can hang on to the bridge. Visualization effect of maintenance inhaler use The protective effect of maintenance medication on the lungs is visualized through the environment and Brad’s physical appearance. Whereas one missed dose is not detrimental (i.e., Brad is able to hang on to the bridge), the negative impact of multiple non-adherence days is represented through a gradual shift towards a greyer and gloomier environment, with Brad sinking deeper. On the other hand, longer streaks of adherent days, result in a stronger Brad, equipped with a diving goggle to be able to endure longer under water (i.e., metaphor for protection of the lungs). The environment also becomes brighter, and users are rewarded with an enriched environment, which for example includes a turtle underwater. Users are provided with a report on the medication usage every three days, represented as intermediate treasure chests. Visualization effect of relieve inhaler use Use of the reliever inhaler is logged through a reliever EMD. When reliever inhaler use is detected, a push-notification is sent to the user, who is then prompted to indicate the reason for use by selecting triggers from a pre-specified list of triggers. Additionally, the user is asked to indicate their level of asthma control using a colour scale. To improve engagement with the app and improve the input of self-monitoring data, which can be a challenging aspect of self- monitoring interventions, the to be filled in form is depicted as a piranha, which transforms upon completion of the form into a friendly-looking fish.
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